FORMULIR PENDAFTARAN

PEMILIHAN DUTA LALU LINTAS KOTA PAGAR ALAM TAHUN 2021

1. NAMA LENGAKAP : ......................................................................................

2. ASAL SEKOLAH : ......................................................................................

3. KELAS / JURUSAN : .......................................................................................

4. TEMPAT TANGGAL LAHIR : .....................................................................................

5. TINGGI BADAN : ......................................................................................

6. BERAT BADAN : .......................................................................................

7. NAMA ORANG TUA :

AYAH : .......................................................................................

IBU : .......................................................................................

8. PEKERJAAN ORANG TUA :

AYAH : .......................................................................................

IBU : .......................................................................................

9. HOBI : .......................................................................................

10. PRESTASI YANG DIMILIKI :

1. ..................................................................................

2. ..................................................................................

3. ..................................................................................

11. EKSUL YANG DIIKUTI : .......................................................................................

Pagara Alam, Juli 2021

FESERTA

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