SURATDELEGASI

Yangbertandatangandibawahini:
Nama :..................................................................................
Jabatan :..................................................................................
NIP :..................................................................................
UnitKerja :..................................................................................
Denganinimemberikanrekomendasikepada:
Nama :..................................................................................
Kelas :..................................................................................
NISN :..................................................................................
Sekolah :..................................................................................
UntukmengikutilombaOlimiadePAI2019Se-EksKaresidenanTingkatWilayahV yang
dilakukanolehHimpunanMahasiswaJurusanPendidikanAgamaIslam(HMJPAI)yang
akandilaksanakanpada:
Hari,tanggal:Mingg,20Oktober2019
Tanggal :20Oktober2019
Tempat :AuditoriumIAINPurwokerto
Acara :LombaOlimpiadePAI2019Se-EksKaresidenanTingkatWilayahV
Demikiansuratrekomendasiinikamibuatsebenar-benarnya,agardapatdipergunakan
sebagaimanamestinya.
...................,....................2019
KepalaSekolah
NIP:
FormulirOlimpiadePAI2019
TingkatSMA/MASederajatSe-EksKaresidenanTingkatWilayahV
A.IdentitasPribadi
NamaLengkap:..................................................................................
TTL :..................................................................................
NISN :..................................................................................
JenisKelamin :..................................................................................
Kelas :..................................................................................
No.Hp :..................................................................................
Alamat :..................................................................................
B.IdentitasSekolah
NamaSekolah :..................................................................................
AlamatSekolah :..................................................................................
No.TelpSekolah :..................................................................................
EmailSekolah :..................................................................................
GuruPendamping:.............................................................................
No.Hp :..................................................................................
..............................,..............................2019
GuruPembimbing SiswaP PesertaOlimpiadePAI
NIP
PasFoto
3x4
(berwarna)
MA
PAD
UN
A​N
suor

TAIN
PURWOK
ERTO
H​MJ
PENDI​DI
KAN
AGAMA
ISLAM
ਸੀ
ਿਕ
ਅ
ਸ

PANITI​A ​OLIMPIADE
PA​L ​HIMPUNAN
​ ASISW​A
M​AH
JURUSAN
PENDIDIKAN ​A​G​AM
​ A ​ISLA​M
INST​IT​UT ​A​G​A​M​A ​IS​LA​M
NEGERI ​PU​RWOKER​T​O
PERIODE ​201​9/​2020 ​S​ekre​tariat​an​:
Gedung Lembaga K ​ emahasiswaa ​ n 1 ​ ​. ​1
J​L a
​ uad Y
​ ani ?
​ l​ o​. ​40 a ​ ​Purw
​ okerto ​Utara​.
Kode P ​ os​ ​52421
CP:​
08570061
6746
(​Lima)​