MAJELIS PERWAKILAN KELAS ( MPK )

SMAN 14 BANDUNG
Jl. Yudhawastu Pramuka I No.IV, Cicadas, Kec. Cibeunying Kidul, Kota Bandung,
Jawa Barat 40121
FORMULIR PENDAFTARAN
PENGURUS MPK (PERIODE 2020/2021)

Nama :_______________________________________________________________

Tempat, Tanggal Lahir :_______________________________________________________________

Alamat Rumah :_______________________________________________________________

_______________________________________________________________

Kelas :_______________________________________________________________

Nama Orang Tua :_______________________________________________________________

Nomor Telp. / Hp :_______________________________________________________________

Cita – cita :_______________________________________________________________

Motto Hidup :_______________________________________________________________

Alamat

 EMAIL :_______________________________________________________________
 INSTAGRAM :_______________________________________________________________
 TWITTER :_______________________________________________________________

Pengalaman Berorganisasi : ___________________________ Jabatan_____________________________

____________________________Jabatan_____________________________

____________________________Jabatan_____________________________

Prestasi

•• AKADEMIK :_______________________________________________________________

•• NON-AKADEMIK :_______________________________________________________________

Jabatan yang diinginkan

⬜ Evaluator
⬜ Aspirator
⬜ Planner
 ………,……… (Bulan) (Tahun)

Tanda Tangan Orang Tua Calon Pengurus

3x4
Materai

(…………………………………………) (……………………………………………………)

NB :

(•) Bila mempunyai.

(••) Diisi tingkat tertinggi.

Foto 3 x 4 (tulis nama dibalik foto).