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FORMULIR UJIAN
EKSTRAKURIKULER KARATE IBNU TAIMIYAH

NAMA LENGKAP :...................................................................................................

TEMPAT / TGL LAHIR :....................................................................................................

JENIS KELAMIN :....................................................................................................

KELAS :.....................................................................................................

ALAMAT :.....................................................................................................

NO. WA/EMAIL :.....................................................................................................

CABANG : SUKAJADI

RANTING/DOJO : SD IBNU TAIMIYAH

KYU TERAKHIR :....................................................................................................

KIHON KATA NILAI

Bandung, Februari 2023


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Pelatih Karate

(CEPPI SUPRIADI,S.Pd) (............................................)

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