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FORMULIRPENDATAANGUGUSDEPANK

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(*)

Cianjur, ..... Oktober 2022

Ketua Gudep .......... Ketua Gudep ..........

(.......….............................................) (.......….............................................)
NTA. ......................................... NTA. .........................................

Mengetahui
Kepala Sekolah SD/SMP/SMA .......
Selalu Ketua Mabigus ........-........

(......….............................................)
NTA. ............................................

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