FORMULIR PENDAFTARAN
Nomor Induk
:.....................................................................................................................
Nama Lengkap
:.....................................................................................................................
Tempat/Tgl. Lahir
:.....................................................................................................................
Asal Sekolah
:.....................................................................................................................
Golongan Darah
:.....................................................................................................................
Anak ke
:.....................................................................................................................
Bapak
:.....................................................................................................................
Ibu
:.....................................................................................................................
Wali
:.....................................................................................................................
:.....................................................................................................................
Alamat Lengkap/Telp
:.....................................................................................................................
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Foto berjilbab
Jombang,,.
Wali Santri
Pengasuh Asrama
(..)