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KAB/KOTA : ………………………..

BIODATA PENERIMA BANTUAN


(Tulis dengan Hurup Kapital/Besar)
I. DATA PERORANGAN

1. Nama Lengkap : ................................................................................................

2. Tgl & Tempat Lahir : ................................................................................................

3. Jabatan : Kpl SMA/MA ......……….…....……………………………………………………

4. Alamat Tinggal : ................................................................................................

5. Nomor KTP : ................................................................................................

6. No. Telp/HP : ................................................................................................

7. Alamat Email : ................................................................................................

II DATA LEMBAGA

1. Nama Lembaga : SMA/MA ………….…………………………………………………………………

2. Alamat Lembaga : ……………………………………………………………………………………………..

……………………………………………………………………………………………..

3. Telpon : ……………………………………………………………………………………………..

4. Alamat Email : ……………………………………………………………………………………………..

 REKENING BANK (An. Sekolah)

Nama Bank : ……………………………………………………………………………………………..


Cabang/KCP/Unit : ................................................................................................
No. Rekening : ……………………………………………………………………………………………..

Atas Nama : ……………………………………………………………………………………………..

Bandung, 2018

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Nama lengkap