FORMULIR PENDAFTARAN

“DIKLAT PENGASUH ASRAMA SANTRI”

7 – 8 AGUSTUS 2019 BATCH 12

NAMA LENGKAP : ________________________________________________________

( dengan gelar pendidikan)
NAMA PANGGILAN : ________________________________________________________
PENDIDIKAN TERAKHIR : ________________________________________________________

ALAMAT LENGKAP : ________________________________________________________

NO. HP / WA : ________________________________________________________

ALAMAT E-MAIL : ________________________________________________________

FACEBOOK : ________________________________________________________

INSTAGRAM : ________________________________________________________

NAMA LEMBAGA/PONPES : ________________________________________________________

JABATAN : ________________________________________________________

NAMA PIMPINAN PONPES : ________________________________________________________

NO. HP PIMPINAN PONPES : ________________________________________________________

ALAMAT PONPES : ________________________________________________________

NO. TELP PONPES : _________________________________________________________

JUMLAH SANTRI : _________________________________________________________

JUMLAH MUSYRIF/ : _________________________________________________________

PENGASUH ASRAMA
MOTIVASI MENGIKUTI : _________________________________________________________

DIKLAT _________________________________________________________

_____________________, _____ ____________ 2019

(_________________________)

KETERANGAN:
Biaya diklat dapat ditransfer melalui Rekening Bank Syariah Mandiri (BSM) a/n Griya Parenting Indonesia dengan
no rekening 7500 600 898 atau 7600 700 892.