FORMULIR PENDAFTARAN

ANGGOTA GERAKAN PEMUDA ANSOR

RANTING DESA MANGGUNGSARI
WELERI
JL. Masjid Al Muttaqin Desa Manggungsari Weleri Kendal Kode pos 51355 Hp.
083127429845

FORMULIR PENDAFTARAN

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

Nama Panggilan :……………………………………………………………………………..
Tempat, tgl lahir : ...................................................................umur ............. Tahun
Alamat : ............................................................................................................
Telpon/HP : ...........................................................................................................
Email : ...........................................................................................................
Status : Kawin/Blm Kawin/Sudah Pernah*
Nama Istri : ……………………………………………………………………………
Jumlah Anak : ……………………………………………………………………………
Pekerjaan : ……………………………………………………………………………

Riwayat Pendidikan :
a. TK : .................................................................. lulus tahun ...............
b. SD/MI : .................................................................. lulus tahun ...............
c. SMP/MTs : .................................................................. lulus tahun ...............
d. SMA/MA/SMK : .................................................................. lulus tahun ...............
e. S.1 : .................................................................. lulus tahun ...............
f. S.2 : .................................................................. lulus tahun ...............

Riwayat Pendidikan Non Formal (Pesantren/Madrasah) :

a. .....................................................................................................................................
b. .....................................................................................................................................
c. .....................................................................................................................................

Pengalaman organisasi
a. .....................................................................................................................................
b. .....................................................................................................................................
c. .....................................................................................................................................
d. .....................................................................................................................................
e. .....................................................................................................................................

........................., ...........................

Foto 3x4 Yang membuat,

2 lbr
berwarna

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Keterangan :
* coret salah satu