PANITIA PELAKSANA

PELATIHAN KEPEMIMPINAN LANJUTAN & KURSUS BANSER LANJUTAN

PC GP ANSOR KABUPATEN PEKALONGAN
34 - X Jl. Raya Karangdowo 09, Kedungwuni Kab. Pekalongan 51173 34 - X

DATA DIRI PESERTA

KURSUS BANSER LANJUTAN II
PC GP ANSOR PEKALONGAN TAHUN 2018

1. Nama Lengkap : ..............................................................................................

2. Tempat Tgl Lahir : ..............................................................................................
3. Alamat : ..............................................................................................
...............................................................................................
4. No hp / WA : ...............................................................................................
5. Pekerjaan : ..............................................................................................
6. Pendidikan Terakhir : SD/MI - SMP/MTs – SMA/SMK/ Aliyah – PT ( dilingkari )
Pesantren / Madrasah : ..............................................................................................
7. Utusan dari : ..............................................................................................
8. Tahun Lulus Diklatsar : ...............................................................................................
9. Unit Banser yg diikuti : ................................................................................................
10. Beladiri yg diikuti : ...................................Tingkatan............................................
11. Thoriqoh yg ikuti : .... ...........................................................................................
12. Wirid / amalan harian : ...............................................................................................
13. Pengalaman Organisasi : ..............................................................................................
..............................................................................................
..............................................................................................
14. Motivasi mengikuti SUSBALAN : ....................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

Pekalongan, ....................................2018

Pas Photo Hormat Kami

3X4

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 PANITIA PELAKSANA
PELATIHAN KEPEMIMPINAN LANJUTAN & KURSUS BANSER LANJUTAN
PC GP ANSOR KABUPATEN PEKALONGAN
34 - X Jl. Raya Karangdowo 09, KedungwuniKab. Pekalongan 51173 34 - X

DATA DIRI PESERTA

PELATIHAN KEPEMIMPINAN LANJUTAN III
PC GP ANSOR PEKALONGAN TAHUN 2018

1. Nama Lengkap : ..............................................................................................

2. Tempat Tgl Lahir : ..............................................................................................
3. Alamat : ..............................................................................................
...............................................................................................
4. No hp / WA : ...............................................................................................
5. Pekerjaan : ..............................................................................................
6. Pendidikan Terakhir : SD/MI - SMP/MTs – SMA/SMK/ Aliyah – PT ( dilingkari )
Pesantren / Madrasah : ..............................................................................................
7. Utusan dari : ..............................................................................................
8. Tahun Lulus PKD : ...............................................................................................
9. Bahasa Asing : ...........................................................................(aktif / pasif )
10. Thoriqoh yg diikuti : .... ...........................................................................................
11. Wirid / amalan harian : ...............................................................................................
12. Pengalaman Organisasi : ..............................................................................................
..............................................................................................
..............................................................................................
13. Motivasi mengikuti PKL : ..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

Pekalongan, ....................................2018

Pas Photo Hormat Kami

3X4

( ..................................................)