PONDOK PESANTREN TAHFIDZ

MUTIARA UMMAT
SK MENTERI KEHAKIMAN RI NO. C-132.HT. 03.01. 1996
NOTARIS SRI BANDINGSIH,SH. BEKASI NO.15 THN 2009

Alamat : Kavling Rawa Mulya, Ciketing Asem RT 04/03 Mustika Jaya.

Kota Bekasi 087809956526/081210482868

BIODATA SANTRI
A. IDENTITAS PRIBADI

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

2. Tempat/tgl lahir : ...........................................................................................................

3. Jenis Kelamin : ...........................................................................................................

4. Alamat sekarang : ...........................................................................................................

5. Nomor HP/tlp : ...........................................................................................................

6. Email : ...........................................................................................................

B. IDENTITAS PENDIDIKAN TERKAHIR

1. Nama Sekokah Asal : ...........................................................................................................

2. Alamat Sekolah : ...........................................................................................................

3. Tanggal Ijaza : ...........................................................................................................

4. Prestasi : ...........................................................................................................

C. IDENTITAS ORANG TUA/WALI

1. Nama

a. Ayah : ...........................................................................................................

b. Ibu : ...........................................................................................................

2. Pekerjaan

a. Ayah : ...........................................................................................................

b. Ibu : ...........................................................................................................

3. Pendidikan

a. Ayah : ...........................................................................................................

b. Ibu : ...........................................................................................................

4. Pendapatan Perbulan : ...........................................................................................................

5. Sumber biaya pendidikan : ...........................................................................................................

6. Nomor tlp : ...........................................................................................................

7. Alamat sekarang : ...........................................................................................................

8. Riwayat Penyakit : ...........................................................................................................

D. LAMPIRAN

a. Pas Foto ukuran :

1) 3 x 4 = 2 lembar

2) 4 x 6 = 2 lembar

b. Foto copy :

1) STTB/IJAZAH

2) SKHUN

3) FOTO COPY KTP

Bekasi, ............................20.... Petugas Pendaftar

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