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PANITIA PELAKSANA

PELATIHAN KEPEMIMPINAN DASAR (PKD)


PC GERAKAN PEMUDA ANSOR
KOTA METRO
Jl. Soekarno Hatta No. 73 Mulyojati 16B Metro Barat Kota Metro HP. 081271860669 / 081279515281

FORMULIR PENDAFTARAN PESERTA


PELATIHAN KEPEMIMPINAN DASAR ( PKD )
TAHUN 2021

NAMA : ....................................................................................................
TEMPAT/TGL LAHIR : ....................................................................................................
KECAMATAN : ....................................................................................................
KELURAHAN : ....................................................................................................
NO. HP : ....................................................................................................
E-MAIL : ....................................................................................................
RIWAYAT PENDIDIKAN : ....................................................................................................
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RIWAYAT ORGANISASI : ....................................................................................................
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RIWAYAT KESEHATAN : ....................................................................................................
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Dengan ini saya menyatakan bersedia untuk mengikuti keseluruhan rangkaian kegiatan Pelatihan
Kepemimpinan Dasar ( PKD ) PC GP Ansor Kota Metro.

CP. 085369200093
Metro, ........................... 2021
Persyaratan peserta
 Rekomendasi ranting/PAC Ansor setempat
 Mengisi formulir pendaftaran dan menyatakan
kesediaan
 Pas photo 3x4 3lembar
 Fotokopi KK dan KTP
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Perlengkapan peserta
 Kemeja/koko putih lengan panjang dan celana
panjang(bukan jeans)
 Kaos berkerah
 Peci hitam
 Sarung
 Perlengkapan mandi/pribadi

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