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PENGURUS CABANG NAHDLATUL ULAMA

KABUPATEN PEKALONGAN
Alamat : : Jl. Raya Karangdowo No. 09 Kedungwuni - Pekalongan 51173 Telp/Fax. (0285) 785903

FORMULIR JAMAAH SENSUS WARGA NU KAB. PEKALONGAN


NIK :
Nama :
:
Jenis Kelamin : Laki-Laki / Perempuan Golongan Darah : ..............
Tempat Lahir : ........................................................................................................
Tanggal Lahir : .......... / ............................ / ................. (Tanggal / Bulan / Tahun )
Alamat : ........................................................................................................
RT RW
Kecamatan : ........................................................................................................
Kode Pos :
Pengurus : Ya Tidak
Banom / Lembaga : ........................................................................................................
Periode : ........................................................................................................
Jumlah Anak : ..................... Orang
Kelompok Ngaji : ........................................................................................................
Pendidikan : ........................................................................................................
Pekerjaan : ........................................................................................................
Penghasilan : < 1.000.000 < 3.000.000 < 5.000.000 > 5.000.000
Nomor WA : ........................................................................................................
Akun FB : ........................................................................................................
Email : ........................................................................................................

..................................... / / 20..........
Setuju di Sensus Petugas Sensus
Nama : Nama :
................................... ...................................
Tanda Tangan Tanda Tangan

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

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