FORMULIR PENDAFTARAN PP AL HASANAH

1. Nama : ......................................................................
2. Jenis kelamin : Laki – laki/ perempuan
3. Tempat tanggal lahir : ......................................................................
4. Anak ke : ......................................................................
5. Jumlah saudara : ......................................................................
6. Alamat : ......................................................................
........................................................................
7. Nama orang tua : ayah.................. ibu.................................
8. Pend. Orang tua : ayah.................... ibu.................................
9. Pekerj. Orang tua : ayah.................... ibu..................................
10. Agama : ISLAM
11. Alamat orang tua : ......................................................................
12. Nama wali : ......................................................................
13. Pendidikan wali : ......................................................................
14. Agama wali : ......................................................................
15. Alamat wali : ......................................................................
16. No. Telp/e-mail : ......................................................................
17. Sekolah Asal : ...................................................................... .....

Mengetahui
Direktur KMI AL HASANAH

( Ust. Amiruddin )