PENGURUS CABANG

PERGERAKAN MAHASISWA ISLAM INDONESIA

(Branch Board Of Indonesian Moslem Student Movement)
KOTA MALANG
Kantor : Jl. Mayjend Pandjaitan No. 164 Malang 65113 Telp. 085732388628
Website : http//www.pmiikotamalang.or.id Email: pmii.pcmalang@gmail.com
BIODATA ANGGOTA
NO : ...................................................................................................................
Nama : ...................................................................................................................
TTL : ...................................................................................................................
Alamat Di Malang : ...................................................................................................................
No. HP : ……………………………………………………………………………
Alamat Asli : ...................................................................................................................
Jur/Fak/Univ : ....................................................................Semester: ..............................
Asal Rayon & Koms. : ...................................................................................................................
Nama Orang Tua
Ayah : ...................................................................................................................
Ibu : ...................................................................................................................
Pekerjaan
Ayah : ...................................................................................................................
Ibu : ...................................................................................................................
: Nama Lembaga Tahun
:
:
Riwayat Pendidikan
:
:
:

: Nama Lembaga Jabatan Tahun

:
:
PengalamanOrganisasi
:
:
:

No. Hp & Email. : ....................................................................................................................

Minat yang di tekuni : ....................................................................................................................
......................................................................................................................
Motivasi Masuk PMII : ....................................................................................................................
......................................................................................................................
......................................................................................................................

Taqwa, Intelektual dan Professional

 PENGURUS CABANG
PERGERAKAN MAHASISWA ISLAM INDONESIA
(Branch Board Of Indonesian Moslem Student Movement)
KOTA MALANG
Kantor : Jl. Mayjend Pandjaitan No. 164 Malang 65113 Telp. 085732388628
Website : http//www.pmiikotamalang.or.id Email: pmii.pcmalang@gmail.com
BIODATA KADER
NO : ...................................................................................................................
Nama : ...................................................................................................................
TTL : ...................................................................................................................
Alamat Di Malang : ...................................................................................................................
No. HP : ……………………………………………………………………………
Alamat Asli : ...................................................................................................................
Jur/Fak/Univ : ....................................................................Semester: ..............................
Asal Rayon & Koms. : ...................................................................................................................
Nama Orang Tua
Ayah : ...................................................................................................................
Ibu : ...................................................................................................................
Pekerjaan
Ayah : ...................................................................................................................
Ibu : ...................................................................................................................
: Nama Lembaga Tahun
:
:
Riwayat Pendidikan
:
:
:

: Nama Lembaga Jabatan Tahun

:
:
PengalamanOrganisasi
:
:
:

No. Hp & Email. : ....................................................................................................................

Minat yang di tekuni : ....................................................................................................................
......................................................................................................................
Motivasi Masuk PMII : ....................................................................................................................
......................................................................................................................
......................................................................................................................

Taqwa, Intelektual dan Professional

 PENGURUS CABANG
PERGERAKAN MAHASISWA ISLAM INDONESIA
(Branch Board Of Indonesian Moslem Student Movement)
KOTA MALANG
Kantor : Jl. Mayjend Pandjaitan No. 164 Malang 65113 Telp. 085732388628
Website : http//www.pmiikotamalang.or.id Email: pmii.pcmalang@gmail.com

BERITA ACARA KEGIATAN

Telah dilaksanakan proses kegiatan formal berupa .........................................................................

Pada Tanggal, Bulan dan Tahun ......................................................................................................

Bertempat di ....................................................................................................................................

Instansi penyelenggara *Komisariat/Rayon ....................................................................................

Jumlah peserta kegiatan ...................................................................................................................

#Delegasi asal peserta kegiatan :

*Komisariat/Rayon .......................................................... Cabang ..................................................

Jumlah .............................................
*Komisariat/Rayon .......................................................... Cabang ..................................................
Jumlah .............................................
*Komisariat/Rayon .......................................................... Cabang ..................................................
Jumlah .............................................
*Komisariat/Rayon .......................................................... Cabang ..................................................
Jumlah .............................................
*Komisariat/Rayon .......................................................... Cabang ..................................................
Jumlah .............................................
*Komisariat/Rayon .......................................................... Cabang ..................................................
Jumlah .............................................

Mengetahui, Mengetahui, Mengetahui,

PK. PMII .................................. PR. PMII .................................. Panitia Pelaksana

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

Ketua Ketua Ketua

*Coret yang tidak perlu.

#Diisi apabila ada delegasi dari luar Instansi penyelenggara.

Taqwa, Intelektual dan Professional