DINAS PENDIDIKAN
Komplek Perkantoran Bukit Tengah
SIULAK
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A. Identitas Siswa/Mahasiswa
Nama : ..............................................................................................................
Alamat : .............................................................................................................
Usia : .............................................................................................................
Anak ke :..............................................................................................................
Jenis Kelamin :L/P
Asal Sekolah/Pontren : ............................................................................................................
Kelas : .............................................................................................................
Tel/Hp : ..............................................................................................................
Jumlah Hapalan ...................JUZ
B.Identitas Orang tua/Wali
Nama : .............................................................................................................
Alamat : .............................................................................................................
Pekerjaan Orang Tua
- Ayah :......................................................................
- Ibu :......................................................................
Pendidikan Terakhir
- Ayah :......................................................................
- Ibu :......................................................................
Tel/HP :.......................................................................
Persyaratan
1. Bukti masih aktif sebagai Pelajar dan Mahasiswa (Raport atau Transkrip Nilai)
2. Kartu Keluarga (Kabupaten Kerinci) dan KTP
Kerinci,................................................ 2020
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