FORMULIR PENDAFTARAN

SANTRI MUQIM BARU

PONDOK PESANTREN ASSALAFIY AL IKHLAS
JL. Sriwijaya Kaliboto Tarokan –Kediri Jawa Timur (64152) Telp./Fax: (0354)3782352, Email: yppsisialikhlas72@gmail.com

A. KETERANGAN CALON SANTRI

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

2. Jenis Kelamin : ................................................................................................................................

3. Tempat & Tgl. Lahir : ................................................................................................................................

4. Agama : ................................................................................................................................

5. Anak Ke : ............................. Dari ............................................................... Bersaudara

6. Status dalam Keluarga : Anak Kandung / Anak Tiri

7. Jumlah : Saudara Kandung : ............................................................... Orang.

: Saudara Tiri : ............................................................... Orang.

8. Alamat Lengkap : ................................................................................................................................

B. KETERANGAN ORANG TUA/WALI

1. Nama Orang Tua : Ayah ................................. Ibu ............................................................

2. Pendidikan Orang Tua : Ayah ................................. Ibu ............................................................

3. Pekerjaan Orang Tua : Ayah ................................. Ibu ............................................................

4. Agama : Ayah ................................. Ibu ............................................................

5. Alamat Orang Tua : ................................................................................................................................

6. Nama Wali : ................................................................................................................................

7. Agama Wali : ................................................................................................................................

8. Pekerjaan Wali : ................................................................................................................................

9. Pendidikan Wali : ................................................................................................................................

10. Alamat Wali : ................................................................................................................................

C. LAMPIRAN PERSYARATAN

1. Membayar Uang Pendaftaran Rp. 20.000,-

2. Membayar syahriyah kamar selama 3 bulan. Rp.20.000/bulan x 3bln = Rp. 60.000,-

Rp. 20.000 + Rp. 60.000 = Rp. 80.000,-

3. Harus diantarkan orang tua.

D. KETERANGAN

1. Nama & Tgl. Lahir harap disesuaikan dengan Akta Kelahiran

2. Harap ditulis dengan huruf Balok/Besar

Kediri, ...............................................
Orang Tua/Wali Nama Santri

( ..................................... ) ( ..................................... )
No. Hp : No. Hp :