MAHAD TARBIYYAH AL ATHFAL AL MANSHUROH

Alamat : Brobot Rt 04/II, Bojongsari Purbalingga 53362

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FORMULIR PENDAFTARAN
1. Nama

: ..........................................................................................................................

a. Nama Lengkap

:...........................................................................................................................

b. Nama Panggilan

:...........................................................................................................................

2. Jenis kelamin

:...........................................................................................................................

3. Tempat dan Tgl lahir

:...........................................................................................................................

4. Anak ke

: dari .. saudara

5. Alamat

:...........................................................................................................................
............................................................................................................................

Tlp/HP

:...........................................................................................................................

6. Nama Orang Tua

a. Ayah

:...........................................................................................................................

b. Ibu

:...........................................................................................................................

7. Alamat Orang Tua

:...........................................................................................................................
............................................................................................................................

Tlp/HP

:...........................................................................................................................

8. Pekerjaan Orang Tua

:...........................................................................................................................

9. Nama Wali

:...........................................................................................................................

10. Alamat Wali

:...........................................................................................................................
............................................................................................................................

Tlp/HP
11. Pekerjaan Wali

:............................................................................................................................
:...........................................................................................................................

Purbalingga, ..2014
Orang tua / Wali Anak Didik Baru

Mohon semua diisi / ditulis dengan huruf kapital / huruf besar