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PANITIA

PELATIHAN KEPEMIMPINAN DASAR GP ANSOR


DAN LATIHAN KADER DASAR FATAYAT NU
KABUPATEN SAMBAS
Contact Person: Bob Andrain, M.Sos (0813-9433-3501), Halim Setiawan, M.Sos (0858-2275-7882)

FORMULIR PESERTA
Nama Lengkap : ..................................................................................................
Tempat Lahir : ..................................................................................................
Tgl, Bln dan Tahun Lahir : ..................................................................................................
Pekerjaan : ..................................................................................................
Pendidikan Terakhir : ..................................................................................................
Alamat : ..................................................................................................
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Desa/Kelurahan : ..................................................................................................
Kecamatan : ..................................................................................................
Kabupaten/Kota : ..................................................................................................
No. HP : ..................................................................................................
No.WA : ..................................................................................................
E-Mail : ..................................................................................................
Facebook : ..................................................................................................
Utusan : ..................................................................................................
Pengalaman Organisasi 1 ..................................................................................................
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Sambas, ….. Januari 2018

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