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PANITIA PELAKSANA

PEMBENTUKAN ANGGOTA PENGURUS MPK MASA BAKTI 2022


MADRASAH ALIYAH NEGERI KOTA PALANGKA RAYA
Jalan Tjilik Riwut Km. 4,5 Palangkaraya 73112 Telp. (0536) 3231286 Faks. (0536) 3233969
e-mail : mankoraya@gmail.com website : www.mankotapalangkaraya.sch.id

FORMULIR PENDAFTARAN
CALON ANGGOTA PENGURUS MPK MASA BAKTI 2022

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


Nama Panggilan : ..............................................................................................................
Kelas : ..............................................................................................................
Tempat / Tanggal Lahir : ..............................................................................................................
Jenis Kelamin : ..............................................................................................................
Alamat : ..............................................................................................................
Media Sosial : ..............................................................................................................
Divisi yang ingin Diikut : ☐Divisi Humas ☐Divisi Penilaian
☐Divisi Sekretariat ☐Divisi Kehormatan
☐Divisi Pertimbangan
Pengalaman Organisasi : ..............................................................................................................
.................................................................................................................
Prestasi yang diraih : ..............................................................................................................
(Opsional) .................................................................................................................

Nama Orang Tua/Wali


a. Ayah : ..............................................................................................................
b. Ibu : ..............................................................................................................
c. Wali : ..............................................................................................................
Alamat Orang Tua/Wali : ..............................................................................................................
No. HP : ..............................................................................................................
Alasan Ingin Bergabung :
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
(*untuk pengisian kotak kolom, cukup dicentang saja)

Palangka Ra Palangka Raya, .................... 2022


ya, ...................
Menyetujui, FOTO Menyetujui,
Calon Pengurus Anggota MPK, Orang Tua / Wali Siswa,
3x4

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