PERSAUDARAAN SETIA HATI TERATE

CABANG JEMBER PUSAT MADIUN

Jl. Umbulsari No. 03 Krebet Gumukmas Jember

LEMBAR PENILAIAN
TES KENAIKAN TINGKAT

NAMA : ................................................
TEMPAT, TGL LAHIR : ................................................
ALAMAT : ................................................
RAYON : ................................................
RANTING : ................................................
CABANG : ................................................
DARI TINGKAT SABUK.....................................KE SABUK.....................................

NAMA JURI :........................................................................

GERAKAN JUMLAH
NO MATERI
1 2 3 4 5 6 7 8 9 10
SENAM
DASAR
1
NILAI

JURUS
2
NILAI
SENAM
TOYA
3
NILAI
JURUS
TOYA
4
NILAI

KRIPEN
5
NILAI

BELATI
6
NILAI

TOTAL NILAI
Lulus
KETERANGAN
Tidak Lulus

Jember,...........................................
Penitia Tes

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