DARUL ARQAM DASAR (DAD)

PIMPINAN KOMISARIAT
IKATAN MAHASISWA MUHAMMADIYAH
(Muhammadiyah Student Assosiation )
ITKES MUHAMMADIYAH SIDENRENG RAPPANG
Sekretariat: Jl. H.Andi Abu Bakar. No. 5. CP. 085364596501 Pangkajene, Sidrap 91611
e-mail:pikom.stikesmuhsid@gmail.com

FORMULIR PENDAFTRAN
DARUL ARQAM DASAR

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

2. NIM :.......................................................................................
3. Tempat tanggal lahir :.......................................................................................
4. Alamat :.......................................................................................
5. N0. HP :.......................................................................................
6. Riwayat pendidikan
a. ......................................................................... :............................................................
b. ......................................................................... :............................................................
c. ......................................................................... :............................................................
d. ......................................................................... :............................................................
e. Prodi/Semester :.......................................................................................
7. Bahasa yang dikuasai :.......................................................................................
8. Golongan darah :.......................................................................................
9. Penyakit yang diidap :.......................................................................................
10. Pantangan :.......................................................................................
11. Alasan masuk DAD
a. .........................................................................................................................................
b. .........................................................................................................................................
c. .........................................................................................................................................
12. Syarat-syarat yang harus dipenuhi peserta DAD
a. Membayar kontribusi peserta Rp. 250.000.
b. Foto terbaru (peserta calon IMMawati memakai jilbab), 2 x 3 dan 3 x 4 masing-masing 2
lembar.
c. Membawa perlengkapan ATM (Alat Tulis Menulis) dan Al-Qur’an terjamahan.
d. Peserta calon IMMawati memakai busana muslim (rok panjang hitam,kemeja putih polos,
baju batik, jilbab hitam minimal 3 jari di bawah siku, sepatu hitam), kaos kaki hitam panjang
serta perlengkapan shalat.
e. Peserta calon IMMawan memakai (sepatu, kaos kaki, celana kain hitam, kemeja putih polos,
baju batik, kopiah hitam dan memakai dasi hitam polos).
f. Setelah mengikuti DAD siap mengikuti FOLLOW UP yang diselenggarakan oleh
PIKOM IMM ITKES Muhammadiyah Sidrap.

Sidrap,………………….2021

Mengetahui
Orang tua/wali Calon peserta

……………………… ………………………….

Catatan:
Kontak Person : 0813 3432 8404 (IMMawati Gustriani Indah Masykuri)

0852 3929 9117 (IMMawati Yuniar)