Anda di halaman 1dari 1

3x4 BIODATA PROGRAM BANTUAN

2 Lembar
PROGRAM YATIM
YAYASAN MUSTAHIQ SIDOARJO

DATA PRIBADI
Nama : ..............................................................................................................
Tempat/Tanggal Lahir : ..............................................................................................................
Jenis Kelamin : a. Laki-laki b. Perempuan
Status Sosial : a. Yatim b. Yatim Piatu
Jumlah Saudara : ............................. Anak ke - ..............................................................
Alamat Tinggal : .............................................................................................................
Alamat Panti (Kalau Ada) :..............................................................................................................
DATA PENDIDIKAN
Nama Sekolah : ..............................................................................................................
Alamat Sekolah : ..............................................................................................................
Kelas : ..............................................................................................................
NAMA ORANG TUA/WALI
Nama Ayah : ..............................................................................................................
Nama Ibu : ..............................................................................................................
Pekerjaan Ayah : ..............................................................................................................
Pekerjaan Ibu : ..............................................................................................................
Status Tempat Tinggal : a. RumahSendiri b. Kontrak c. Kos d. ..
Telepon : ..............................................................................................................
DATA MASUK
Tanggal/Bulan/Tahun : ..............................................................................................................
Penanggung Jawab : ..............................................................................................................
Sidoarjo, ..........................................

Penanggung Jawab Penerima Bantuan Program

(...........................................) (.........................................)
Persyaratan :
1. Foto Copy KK > 1 Lembar
2. Pas Foto 3x4 > 2 Lembar

Anda mungkin juga menyukai