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FORMULIR IDENTIFIKASI CALON PENERIMA BANTUAN

PROGRAM SOSIAL BANK INDONESIA (PSBI)

Nama Lembaga/Pemohon..............................................................................:
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Alamat : ...................................................................................

No.Telepon : ...................................................................................

Narasumber dan Jabatan...............................................................................:


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Usulan Kegiatan : ...................................................................................

KELEMBAGAAN (UNIVERSITAS/SEKOLAH)

1. Kapan lembaga berdiri ?


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2. Jelaskan latar belakang, tujuan atau visi lembaga ?
Latar Belakang ...........................................................................................
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Tujuan

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Visi

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Misi

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3. Jelaskan perkembangan lembaga sampai dengan saat ini ?

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Jumlah mahasiswa....................................................................................:

Status akreditasi.......................................................................................:

Program Studi :

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Prestasi dalam dua tahun terakhir (jika ada) :

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4. Jelaskan sumber dana lembaga ?

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5. Jelaskan pengalaman atau track record kegiatan yang dilaksanakan


Lembaga (2 tahun terakhir)?

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6. Jelaskan manfaat keberadaan lembaga bagi masyarakat ?

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KEPENGURUSAN/PESERTA/ANGGOTA (PERPUSTAKAAN)

1. Jelaskan struktur organisasi, jumlah dan siapa yang menjadi pengurus


lembaga?

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

2. Jelaskan latar belakang (sosial ekonomi dan pendidikan)


pengurus/peserta/anggota?

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3. Bagaimana tingkat keaktifan pengurus pada kegiatan di lembaga?

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4. Kondisi perpustakaan :

Jumlah buku yang dimiliki.......................................................................:

Jumlah pustakawan : .................................................................................

Jumlah pengunjung perhari.....................................................................:

Pengolahan Buku : Manual Software .....................................


(Sebutkan)

KEGIATAN

1. Kegiatan apa yang akan dilaksanakan dan membutuhkan bantuan dari


Bank Indonesia ?
Program BI Corner

2. Apa latar belakang dan tujuan dilaksanakannyakegiatan tersebut?

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3
bacaan serta tepat dan berhasil guna serta memupuk minat dan bakat
serta mengembangkan kemampuan untuk memecahkan permasalahan
yang dihadapi

3. Siapa target penerima manfaat kegiatan?


Seluruh warga SMKN 13 Jakarta, Guru, Pegawai dan Siswa
4. Berapa rincian biaya/anggaran kegiatan tersebut?
Sesuai dengan budget program

5. Darimana sumber pendapatan untuk melaksanakan kegiatan tersebut?


Bank Indonesia

4
Jakarta Barat, 20
September 2017
Kepala SMK Negeri 13
Jakarta

Arum Sari, M.Pd.


NIP.
196904141992032014

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