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FORM PROFIL DATA MUSHOLLA

Nama Musholla : .....................................................................................................................................


Alamat Lengkap : .....................................................................................................................................
.....................................................................................................................................
Jenis Tipologi : a. Musholla di tempat Publik b. Musholla Perkantoran
c. Musholla di Sekolahan d. Musholla di Perumahan
No. Telp/Hp : .........................
No. Faks : .........................
Tahun Berdiri : .........................
Izin Mendirikan Bangunan : Nomor : ....................................... Tanggal : .............................................................
Luas Tanah : ......................... M2
Luas Bangunan : ......................... M2
Status Tanah : a. Wakaf b. SHM c. Girik
Jumlah Jama’ah : a. 5-15 b. 16-30 c. 31-50 d. >50
Daya Tampung- : .........................
Maksimal Jama’ah
Jumlah Pengurus Musholla : .........................
Jumlah Imam : .........................
Jumlah Khatib : .........................
Jumlah Muazin : .........................
Jumlah Remaja : .........................
Lokasi Koordinat : Latitude : .......................................... Longitude : .....................................................
Fasilitas Kelengkapan Musholla :

Lain-lain : ...................................................................................................................
...................................................................................................................
Kegiatan Musholla :

Lain-lain : ...................................................................................................................
...................................................................................................................
Sejarah Musholla : ................................................................................. (diterangkan dilembar baliknya)
…………………….,…………………………
Ketua Ta’mir
………………………………………………..

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