FORMULIR PENDAFTARAN PROGRAM TAHFIDZ

WEEKEND

A. KETERANGAN PRIBADI
1. Nama : .............................................................................

2. Nama Panggilan : .............................................................................

3. Jenis Kelamin : .............................................................................

4. Tempat/ Tanggal Lahir : .............................................................................
5. Alamat Rumah : .............................................................................
6. No. Telepon/HP : .............................................................................

B. ORANG TUA
1. Nama Orang Tua/Wali : a. Ayah : .................................................

b. Ibu : .................................................

2. Pekerjaan Orang Tua : .............................................................................

3. Alamat Orang Tua : .............................................................................

4. No. Telepon/HP : .............................................................................

Ngoro, .......,......................, 20...

Ttd

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