PROFIL LEMBAGA

A. Data Umum

1. Identitas Lembaga

a. Jenjang Pendidikan : ............................................................................................

b. Jenis Satuan Pendidikan : ............................................................................................

c. Nama Lembaga : ............................................................................................

d. Alamat lembaga : ............................................................................................

e. Provinsi : ............................................................................................

f. Kabupaten/Kota : ............................................................................................

g. Kecamatan : ............................................................................................

h. Desa/Kelurahan : ............................................................................................

i. RT/RW atau Jalan : ............................................................................................

j. Email : ............................................................................................

k. Nama Kepala : ............................................................................................

l. No. Kontak : ........................................................................................

2. Organisasi Pengelola Lembaga

a. Nama : ............................................................................................

b. Alamat : ............................................................................................

c. Provinsi : ............................................................................................

d. Kabupaten/Kota : ............................................................................................

e. Kecamatan : ............................................................................................

f. Desa/keluarahan : ............................................................................................

g. RT/RW atau Jalan : ............................................................................................

h. No. Akta Yayasan : ............................................................................................

i. No. Sk Kemenkumham : ............................................................................................

j. NPWP : ............................................................................................
 k. Struktur Organisasi

No. Nama Jabatan Alamat

B. Tenaga Pendidik dan Kependidikan

No. Nama Tgl Lahir Pendidikan Jabatan

C. Sarana dan Prasarana

a. Tanah
Luas Tanah : .....................................................................................................
Status Tanah : Milik Sendiri/Milik Yayasan/Sewa/ Lainnya ................................
b. Bangunan
Luas Bangunan : .....................................................................................................
Status Bangunan : Milik Sendiri/Milik Yayasan/Sewa/ Lainnya ................................
JENIS JUMLAH UKURAN KELAYAKAN
LAYAK KURAN TIDAK
Ruang Belajar
Ruang Ibadah
Ruang Kantor
Ruang Bermain
Alat Permainan

D. Peserta didik/santri

No Jenis Kelamin Jumlah Keterangan

1. Laki-Laki
2. Perempuan

Cirebon, 2021
Kepala Lembaga,

....................................................
NIK ..............................................
 STRUKTUR ORGANISASI LEMBAGA
..........................................................................................

Kepala : ..........................................................................................

Sekretaris : ..........................................................................................

Bendahara : ..........................................................................................

Tata Usaha : 1. ......................................................................................

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

Pengajar : 1. ......................................................................................

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

3. .......................................................................................
4. .......................................................................................
5. .......................................................................................

Operator : Nama : .......................................................................

NIK : .......................................................................

No. HP : .......................................................................

Email : .......................................................................

Kepala,

..............................................