:______________________
Tanggal Pendaftaran
:______________________
Pendaftaran Ulang
Tahun Pelajaran
:______________________
A. DATA SANTRI
:
1. Nama Lengkap
:__________________________________________________
2. Tempat/Tgl. Lhr
:__________________________________________________
3. Jenis Kelamin
:__________________________________________________
4. Anak Ke
:_______________Jumlah Saudara Kandung:______________
5. Sekolah Formal Yang Sedang ditempuh
:
- MI/SD
:___________________________________________________
- MTs/SMP
:___________________________________________________
- SMA/SMK
:___________________________________________________
__
__
__
:__
________________________________________________
Tlp./HP
:__________________________________________________
2. Nama Ibu
Umur
Pekerjaan
Pendidikan Terakhir
Alamat
Tlp./HP
:__________________________________________________
: ________tahun.
:__________________________________________________
:__________________________________________________
:__________________________________________________
:__________________________________________________
:__________________________________________________
Ungaran,
Pendaftar
Mengetahui,
Orang Tua/Wali Santri
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