Anda di halaman 1dari 1

FORMULIR PENDAFTARAN ANGGOTA

GERAKAN PEMUDA MINANGKABAU (GPM)


KOTA DUMAI

Nomor Pendaftaran :

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


2. Tempat / Tgl.Lahir : ...............................................................................
3. Alamat Lengkap : ...............................................................................
4. Agama : ...............................................................................
5. Suku : ...............................................................................
6. Nagari Asal : ...............................................................................
7. Pekerjaan : ...............................................................................
8. Gologan Darah : ...............................................................................
9. Hobby : ...............................................................................
10. No.Telpon/ Hp : ...............................................................................
11. Nama Istri / Suami : ...............................................................................
12. Jumlah Anak : ...............................................................................

Catatan :...........................................................................................

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

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

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

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

Dumai,..............................20...

Hormat Saya
*Lingkar Salah Satu
Untuk Ukuran Baju

S M L XL .......

_____________________________

Nama Dan Tanda Tangan Warga

(Pengurus Untuk Registrasi)

Anda mungkin juga menyukai