Petunjuk Pengisian Formulir:

*) diisi dengan lengkap dan menggunakan huruf kapital untuk keperluan sertifikat,
nama pada sertifikat berdasarkan nama pada formulir pendaftaran (Panitia tidak
bertanggungjawab atas kesalahan nama pada sertifikat)
**) coret yang tidak perlu.
Peserta perorangan mengisi kolom Anggota 1 dan peserta beregu mengisi kolom
Anggota 1 - 3.
Formulir dapat digandakan.
____________________________________________________________________________________
No. Transaksi / Kwitansi
: ..................................................................................................................
Tanggal Transaksi / Kwitansi
: ..................................................................................................................
____________________________________________________________________________________
Anggota 1 *)
Nama Lengkap
: ............................................................................................................................
.............
Telp. / HP
: ............................................................................................................................
.............
Sekolah
: ............................................................................................................................
.............
Alamat Sekolah
: ............................................................................................................................
.............
Telp. Sekolah
: ............................................................................................................................
.............
Anggota 2 *)
Nama Lengkap
: ............................................................................................................................
.............
Telp. / HP
: ............................................................................................................................
.............
Sekolah
: ............................................................................................................................
.............
Alamat Sekolah
: ............................................................................................................................
.............
Telp. Sekolah
: ............................................................................................................................
.............
Anggota 3 *)
Nama Lengkap
: ............................................................................................................................
.............
Telp. / HP
: ............................................................................................................................
.............
Sekolah
: ............................................................................................................................
.............
Alamat Sekolah
: ............................................................................................................................
.............

Telp. Sekolah
: ............................................................................................................................
.............
Pendamping *)
Nama Lengkap
: ............................................................................................................................
.............
Asal Sekolah
: ............................................................................................................................
.............
Telp. / Hp
: ............................................................................................................................
.............
Rayon
: ............................................................................................................................
.............
Tingkat **) : SD / SMP / SMA
Klasifikasi **)
: Delegasi / Mandiri
Biaya
: ............................................................................................................................
.............

Pendaftar

(Nama Terang)

Untuk pendaftaran online, Subject e-mail diisi :

Rayon#sekolah#mandiri/delegasi

.......................................... ,
2012
Panitia

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