PANITIA PELAKSANA DARUL ARQAM DASAR

PIMPINAN KOMISARIAT
IKATAN MAHASISWA MUHAMMADIYAH
AR- FACHRUDIN UNIVERSITAS MUHAMMADIYAH KUPANG
Sekretariat : Jl. K.H. Ahmad Dahlan No.17 Kel. Kayu Putih Kec. Oebobo Kota Kupang-NTT
Tep/Hp: 0813 5360 8811 Email: pkimmarfakhrudin22@gmail.com

FORMULIR PENDAFTARAN

A. Biodata Diri.
Nama :..........................................................................
TTL :..........................................................................
Jenis Kelamin : Laki-Laki / Perempuan Pas Foto 3x4
Alamat :..........................................................................
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Telp/Hp :..........................................................................
Email :..........................................................................
Fakultas :..........................................................................
Prodi :...........................................................................................................
Riwayat Penyakit :...........................................................................................................
:...........................................................................................................
Moto Hidup :...........................................................................................................
:...........................................................................................................
:...........................................................................................................
B. Riwayat Pendidikan Formal.

TINGKAT TAHUN
NAMA LEMBAGA
PENDIDIKAN LULUS
TK/RA
SD/MI
SMP/MTs
SMA/MA/SMK

C. Riwayat Organisasi.

JABATAN NAMA ORGANISASI TAHUN

D. Motivasi Mengikuti Pengkaderan.

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Kupang, ….. ……………………. ……….

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