WARTIRCABANG CIANJUR
TAHUN2022
a. DATAGUGUSDEPAN
NamaPangkalan :.........................................................................................................
AlamatPangkalan :.........................................................................................................
Ds/Kel.......................................Kecamatan..................................
KabupatenCianjur–JawaBarat
No.Telpon :.........................................................................................................
No.GudepPutra :.........................................................................................................
No.GudepPutri :.........................................................................................................
b. DATAMABIGUS
NamaLengkap(dengangelar) :........................................................................................................
Alamat :.........................................................................................................
RT/RW............Ds/Kel...........................Kecamatan.....................
Kabupaten Cianjur–JawaBarat
No.HP :.........................................................................................................
MemilikiKTA :YA/TIDAK(*)
MemilikiSHB :YA/ TIDAK(*)
c. DATAKETUAGUDEPPUTRA
NamaLengkap(dengangelar):........................................................................................................
Alamat :.........................................................................................................
RT/RW............Ds/Kel...........................Kecamatan.....................
KabupatenCianjur–JawaBarat
No.HP :.........................................................................................................
MemilikiKTA :YA/TIDAK(*)
MemilikiSHB :YA/ TIDAK(*)
d. DATAKETUAGUDEPPUTRI
NamaLengkap(dengangelar):........................................................................................................
Alamat :.........................................................................................................
RT/RW............Ds/Kel...........................Kecamatan.....................
KabupatenCianjur–JawaBarat
No.HP :.........................................................................................................
MemilikiKTA :YA/TIDAK(*)
MemilikiSHB :YA/ TIDAK(*)
(.......….............................................) (.......….............................................)
NTA. ......................................... NTA. .........................................
Mengetahui
Kepala Sekolah SD/SMP/SMA .......
Selalu Ketua Mabigus ........-........
(......….............................................)
NTA. ............................................