FORMULIR PESERTA

KONVENSI PENDETA GEREJA TORAJA

WILAYAH V KALIMANTAN

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

2. Tempat/tanggal Lahir : .......................................................................................................................................

3. Jenis Kelamin : Laki Laki / Perempuan *
4. Alamat : .......................................................................................................................................

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

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

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

No. WA : .......................................................................................................................................

Nama Jemaat : .......................................................................................................................................

Alamat Jemaat : .......................................................................................................................................

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

Email Jemaat : .......................................................................................................................................

Tlp/Fax : .......................................................................................................................................
5. Riwayat Pelayanan :
No Jabatan Tahun Tempat
1 Proponen
2 Pendeta
3
4
5
6

6. Ukuran Baju : ...........................................................................................

......................., .................. 2018

Peserta

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Formulir ini dikirim kepada panitia paling lambat SABTU/7 Juli 2018 melalui email :
panitiakonvensipendeta@yahoo.com atau melalui WA : 081347248367