NAMA : ........................................................................................
TEMPAT/TANGGAL LAHIR : ........................................................................................
NIM : ........................................................................................
PRODI : ........................................................................................
ALAMAT
Kost : ........................................................................................
Tempat Tanggal Asal : ........................................................................................
No. HP. : ........................................................................................
ALASAN MENGIKUTI UKM PENCAK SILAT PSHT
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ORGANISASI ATAU PERGURUAN YANG DIIKUTI SEKARANG
1. .................................................................................................................................................
2. .................................................................................................................................................
3. .................................................................................................................................................
RIWAYAT PENDIDIKAN
Saya berjanji akan memenuhi semua peraturan-peraturan yang berlaku dalam latihan UKM
pencak silat PSHT, dan akan berlatih dengan tekun serta menghormati pelatih, pengurus dan
sesamanya
Slawi, 20..
Mengetahui,
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