DAFTAR RIWAYAT HIDUP
CALON ANGGOTA KOMISI INFORMASI
KABUPATEN SUMENEP PERIODE 2025 - 2029

1.	Nama				: ....................................................................
2.	Jenis Kelamin			: ....................................................................
3.	Tempat Tgl Lahir/Usia		: ....................................................................
4.	Pekerjaan/Jabatan		: ....................................................................
5.	Alamat				: ....................................................................
				  	  ....................................................................
6.	Status Perkawinan		: ....................................................................
a.	Belum/sudah/pernah Kawin *)
b.	Nama Istri/Suami *)		: ....................................................................	
c.	Jumlah Anak 		: ...........................................................orang	
7.	Pekerjaan			: ....................................................................
8.	Riwayat Pendidikan		:
a.	SD	......................................................................................................
b.	SMP	......................................................................................................
c.	SMA	......................................................................................................
d.	S1	......................................................................................................
e.	S2	......................................................................................................
f.	S3 	......................................................................................................
9.	Pengalaman Pekerjaan	:
a.	.................................................................................................................
b.	.................................................................................................................
c.	.................................................................................................................
d.	.................................................................................................................
e.	.................................................................................................................
10.	Pengalaman Organisasi	:
a.	.................................................................................................................
b.	.................................................................................................................
c.	.................................................................................................................
d.	.................................................................................................................
e.	.................................................................................................................
11.	Penghargaan yang pernah diperoleh
a.	.................................................................................................................
b.	.................................................................................................................
c.	.................................................................................................................
d.	.................................................................................................................
e.	.................................................................................................................

Daftar Riwayat Hidup ini dibuat dengan sebenar-benarnya untuk digunakan sebagai bukti pemenuhan syarat administrasi pendaftaran Calon Anggota Komisi Informasi Kabupaten Sumenep Periode 2025 – 2029 sebagaimana dimaksud dalam Undang-Undang Nomor 14 Tahun 2008 tentang Keterbukaan Informasi Publik.

Sumenep, ..... ............... 2025

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4x6

Pendaftar,

Materai 10.000
(...........................................)

Keterangan : *) Coret yang tidak diperlukan