PANITIA PEMILIHAN

GUK DAN YUK SIDOARJO 2011
Sekretariat :
Komplek Stadion GELORA DELTA
Pintu Timur 8-9 No. 25A SIDOARJO Telp. (031) 77 104 661

FORMULIR PENDAFTARAN PESERTA
PEMILIHAN GUK DAN YUK SIDOARJO 2011
DATA PRIBADI
1. Nama Lengkap
2. Tempat Tanggal Lahir
3. Usia
4. Jenis Kelamin
5. Alamat / No. Telp

:
:
:
:
:

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6. Pendidikan
: ...................................................................................................................
7. Asal Sekolah / Universitas..................................................................................................................:
8. Tinggi / Berat Badan
:
9. Minat dan Bakat
:
10. Pengalaman Organisasi* :
11. Prestasi*
:

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2.................................................................................................................
3.................................................................................................................

Sidoarjo,.....................................2011

Orang Tua

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*bisa dianjutkan di belakang

Panitia

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