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BIODATA PERSERTA

Nama Lengkap :

Tmpt / Tgl Lahir :

No. HP :

Alamat Email :

Gol Darah :

Alamat Peserta :

Nama Perusahaan :

Alamat Perusahaan :

Jenis Alat : Forklif ( ) Mobile Crane ( ) OTC ( )


Excavator ( ) Tower Crane ( ) Gantry Crane ( )
Loader ( ) Crawler Crane ( ) RTG ( )
Bulldozer ( ) Luving Crane ( ) Pedestal Crane ( )
Stacker R. ( ) Container Crane ( ) Ship Crane ( )
Selain diatas ……………

Pengalaman Training K3 :
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Tanda tangan peserta

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Lampiran Salinan KTP Peserta


Salinan Ijasah Peserta
Foto Peserta

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