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FORMULIR PENDAFTARAN

Unit Latihan : ..................................................................................


Nama Lengkap : ..................................................................................

Tempat/Tgl Lahir : ..................................................................................

Jenis Kelamin : ..................................................................................

Agama : ..................................................................................

Pendidikan :.................................................................................................................

Pekerjaan : ................................................................................................................

Alamat Lengkap : ................................................................................................................

................................................................................................................

No. Telp/HP : ................................................................................................................

Pernah Mengikuti Beladiri : Pernah / Belum *) (.................................................)

Nama Orang Tua/ Wali : ...............................................................................................................

Alamat Orang Tua/ wali : ...............................................................................................................

No. Telp/Hp : ...............................................................................................................

“Saya berjanji akan mematuhi semua peraturan-peraturan yang berlaku dalam latihan perguruan silat
Tadjimalela, dan akan berlatih dengan tekun serta menghormati pelatih, pengurus dan sesama
Tadjimalela”

Subang, ........................ 20...

Mengetahui,

Orang Tua/ Wali Murid Pemohon

(.........................................) (.........................................)

*) Coret yang tidak perlu www.tadjimalelasubang.co.cc