MAGNASHOFA
Jln. Banjar-Manonjaya No.253 RT 20 RW 06 Dsn Goler Ds. Beber Kec. Cimaragas Kab. Ciamis 46381
A. IDENTITAS ANAK
1. Nama Lengkap : ........................................................................................
(harus sesuai akta kelahiran atau kartu keluarga )
2. Nama Panggilan : .........................................................................................
3. Tempat dan Tanggal Lahir : ........................................................................................
4. Anak ke : ........................................................................................
5. Agama : ........................................................................................
6. Berat Badan : ........................................................................................
7. Tinggi Badan : ........................................................................................
8. Alamat Rumah : ........................................................................................
Goler, ................................20
Orang Tua/Wali
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Pendapatan :
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Biaya Beban :
Ketua Yayasan
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NERACA
PER 31 DESEMBER .............
Ciamis , ........................