Name : Name :

Dept : Dept :
No. Telp : No. Telp :
Email : Email :
Current Stay Address : Current Stay Address :

NO DOC. QTY NO DOC. QTY

1 Copy of ID / KTP 1 Copy of ID / KTP
2 Copy of Family Card / KK 2 Copy of Family Card / KK
3 Copy of SKCK / Police Record 3 Copy of SKCK / Police Record
4 Copy of Diploma / University Certificate 4 Copy of Diploma / University Certificate
5 Copy of NPWP 5 Copy of NPWP
6 Copy of Marriage Book / Certificate 6 Copy of Marriage Book / Certificate
7 Copy of Health Insurance Card (BPJS Kesehatan) 7 Copy of Health Insurance Card (BPJS Kesehatan)
8 Copy of BPJS Ketenagakerjaan 8 Copy of BPJS Ketenagakerjaan
9 Copy of COVID19 Vaccine Certificate 9 Copy of COVID19 Vaccine Certificate
10 Copy of Bank Account (Mandiri) 10 Copy of Bank Account (Mandiri)
11 Copy of Bank Account (BAG) 11 Copy of Bank Account (BAG)
Emergency contact: Emergency contact:
Name : Name :
12 Relation : 12 Relation :
No. Telp : No. Telp :
Adress : Adress :