FORMULIR PENDAFTARAN UKM PENCAK SILAT PSHT

STIKes BHAMADA SLAWI

NAMA : ........................................................................................
TEMPAT/TANGGAL LAHIR : ........................................................................................
NIM : ........................................................................................
PRODI : ........................................................................................
ALAMAT

 Kost : ........................................................................................
 Tempat Tanggal Asal : ........................................................................................
 No. HP. : ........................................................................................
ALASAN MENGIKUTI UKM PENCAK SILAT PSHT

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ORGANISASI ATAU PERGURUAN YANG DIIKUTI SEKARANG
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RIWAYAT PENDIDIKAN

JENJANG PENDIDIKAN ASAL SEKOLAH TEMPAT

“Saya berjanji akan memenuhi semua peraturan-peraturan yang berlaku dalam latihan
UKM pencak silat PSHT, dan akan berlatih dengan tekun serta menghormati pelatih,
pengurus dan sesamanya”

Slawi, 20..

Mengetahui,

Orang Tua/Wali Murid Pemohon

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Nb. Bawa pas foto 4x6 3 lembar