PW GP ANSOR JAWA TIMUR

BORANG AKREDITASI PIMPINAN ANAK CABANG

Pimpinan Cabang : .....................................................................................................

Pimpinan Anak Cabang : .....................................................................................................

I. STRUKTUR KEPENGURUSAN PIMPINAN ANAK CABANG (PAC)

1. Nomor SK : ..…………………….…………………………… (SK dilampirkan)

2. Masa Bhakti : .......................................................
3. Biodata (Curriculum Vitae) Pengurus dan KTP dilampirkan
4. Sertifikat Kaderisasi seluruh Pengurus dilampirkan

II. MAJELIS DZIKIR DAN SHOLAWAT RIJALUL ANSOR (MDS RA)

1. Nomor SK: …………………….…………………………… (SK dilampirkan)

2. Kegiatan Bulan Januari Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)
2.1 Tgl dan waktu Kegiatan : .....................................................................
2.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
2.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
2.4 Deskripsi Singkat Kegiatan : .................................................................
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2.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

3. Kegiatan Bulan Februari Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

3.1 Tgl dan waktu Kegiatan : .....................................................................
3.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
3.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
3.4 Deskripsi Singkat Kegiatan : .................................................................
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3.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan
4. Kegiatan Bulan Maret Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)
4.1 Tgl dan waktu Kegiatan : .....................................................................
4.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
4.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
4.4 Deskripsi Singkat Kegiatan : .................................................................
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4.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

5. Kegiatan Bulan April Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

5.1 Tgl dan waktu Kegiatan : .....................................................................
5.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
5.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
5.4 Deskripsi Singkat Kegiatan : .................................................................
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5.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

6. Kegiatan Bulan Mei Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

6.1 Tgl dan waktu Kegiatan : .....................................................................
6.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
6.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
6.4 Deskripsi Singkat Kegiatan : .................................................................
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6.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

7. Kegiatan Bulan Juni Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

 7.1 Tgl dan waktu Kegiatan : .....................................................................
7.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
7.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
7.4 Deskripsi Singkat Kegiatan : .................................................................
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7.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

8. Kegiatan Bulan Juli Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

8.1 Tgl dan waktu Kegiatan : .....................................................................
8.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
8.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
8.4 Deskripsi Singkat Kegiatan : .................................................................
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8.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

9. Kegiatan Bulan Agustus Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

9.1 Tgl dan waktu Kegiatan : .....................................................................
9.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
9.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
9.4 Deskripsi Singkat Kegiatan : .................................................................
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9.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan
10. Kegiatan Bulan September Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)
10.1 Tgl dan waktu Kegiatan : .....................................................................
10.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
10.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
10.4 Deskripsi Singkat Kegiatan : .................................................................
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10.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

11. Kegiatan Bulan Oktober Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

11.1 Tgl dan waktu Kegiatan : .....................................................................
11.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
11.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
11.4 Deskripsi Singkat Kegiatan : .................................................................
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11.5 Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

12. Kegiatan Bulan November Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

12.1. Tgl dan waktu Kegiatan : .....................................................................
12.2. Jumlah Peserta : .............. Orang (Absen dilampirkan)
12.3. Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
12.4. Deskripsi Singkat Kegiatan : .................................................................
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12.5. Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan
13. Kegiatan Bulan Desember Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)
13.1. Tgl dan waktu Kegiatan : .....................................................................
13.2. Jumlah Peserta : .............. Orang (Absen dilampirkan)
13.3. Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
13.4. Deskripsi Singkat Kegiatan : .................................................................
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13.5. Foto dan Dokumentasi Kegiatan di lampirkan
III. KADERISASI (PKD & DIKLATSAR)

1. PELATIHAN KEPEMIMPINAN DASAR (PKD)

1.1 SK Panitia PKD : .....................................................................
1.2. Tgl dan waktu Kegiatan : .....................................................................
1.3. Jumlah Peserta : .............. Orang (Absen dilampirkan)
1.4. Instruktur dan Nara Sumber : 1) ................................................................
: 2) ................................................................
: 3) ................................................................
1.5. Deskripsi Singkat Kegiatan : .................................................................
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1.6. Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan

2. PENDIDIKAN DAN PELATIHAN DASAR (DIKLATSAR) BANSER

2.1 SK Panitia DIKLATSAR : .....................................................................
2.2. Tgl dan waktu Kegiatan : .....................................................................
2.3. Jumlah Peserta : .............. Orang (Absen dilampirkan)
2.4. Instruktur dan Nara Sumber : 1) ................................................................
: 2) ................................................................
: 3) ................................................................
2.5. Deskripsi Singkat Kegiatan : .................................................................
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2.6. Foto Dokumentasi Kegiatan dan daftar hadir di lampirkan
IV.BARISAN ANSOR SERBAGUNA (BANSER)

1 Nomor SK : …………………….…………………………… (SK SATKORYON dilampirkan)

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1.1 Jumlah Anggota : ……………. Personil (biodata/KTA anggota dilampirkan)
1.2 Photo dan dokumentasi kegiatan dilampirkan

2 Unit Khusus Banser ........................................................

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2.1. Nomor SK : …………………….…………………………… (SK dilampirkan)
2.2. Jumlah Anggota : ……………. Personil (biodata/KTA anggota dilampirkan)
2.3. Photo dan dokumentasi kegiatan dilampirkan

3 Unit Khusus Banser ........................................................

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3.1. Nomor SK : …………………….…………………………… (SK dilampirkan)
3.2. Jumlah Anggota : ……………. Personil (biodata/KTA anggota dilampirkan)
3.3. Photo dan dokumentasi kegiatan dilampirkan

4 Unit Khusus Banser ........................................................

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4.1. Nomor SK : …………………….…………………………… (SK dilampirkan)
4.2. Jumlah Anggota : ……………. Personil (biodata/KTA anggota dilampirkan)
4.3. Photo dan dokumentasi kegiatan dilampirkan
V. STRUKTUR KEPENGURUSAN PIMPINAN RANTING (PR)

1 Jumlah Desa/Kelurahan: …………………………………………………………………………………….

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1.1. Jumlah Ranting : .................. (SK Dilampirkan)
1.2. Profil Pengurus Ranting dilampirkan
1.3. Sertifikat Kaderisasi Ketua, Sekretaris, Bendahara & Kasatkorkel dilampirkan
1.4. Hasil Akreditasi Ranting (SK 1) Ranting ............................... Akreditasi ......................
Penetapan Akrteditasi Pimpinan 2) Ranting ............................... Akreditasi ......................
Ranting dilampirkan) 3) Ranting ............................... Akreditasi ......................
4) Ranting ............................... Akreditasi ......................
5) Ranting ............................... Akreditasi ......................
6) Ranting ............................... Akreditasi ......................
7) Ranting ............................... Akreditasi ......................
8) Ranting ............................... Akreditasi ......................
VI.KEGIATAN SOSIAL KEMASYARAKATAN & KEPEMUDAAN

1. KEGIATAN SOSMAS & KEPEMUDAAN BULAN JANUARI – MARET

1.1. Nama Kegiatan/Acara : .....................................................................
1.2. Nomor SK Panitia : …………………….……………………………(SK dilampirkan)
1.3. Tgl dan waktu Kegiatan : .....................................................................
1.4. Jumlah Peserta : .............. Orang (Absen dilampirkan)
1.5. Nara Sumber /Pembicara : 1) ................................................................
/Undangan Eksternal : 2) ................................................................
: 3) ................................................................
1.6. Deskripsi Singkat Kegiatan : .................................................................
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1.7. Foto dan Dokumentasi Kegiatan di lampirkan
2. KEGIATAN SOSMAS & KEPEMUDAAN BULAN APRIL – JUNI
2.1. Nama Kegiatan/Acara : .....................................................................
2.2. Nomor SK Panitia : …………………….……………………………(SK dilampirkan)
2.3. Tgl dan waktu Kegiatan : .....................................................................
2.4. Jumlah Peserta : .............. Orang (Absen dilampirkan)
2.5. Nara Sumber /Pembicara : 1) ................................................................
/Undangan Eksternal : 2) ................................................................
: 3) ................................................................
2.6. Deskripsi Singkat Kegiatan : .................................................................
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2.7. Foto dan Dokumentasi Kegiatan di lampirkan
3. KEGIATAN SOSMAS & KEPEMUDAAN BULAN JULI - SEPTEMBER
3.1. Nama Kegiatan/Acara : .....................................................................
3.2. Nomor SK Panitia : …………………….……………………………(SK dilampirkan)
3.3. Tgl dan waktu Kegiatan : .....................................................................
3.4. Jumlah Peserta : .............. Orang (Absen dilampirkan)
3.5. Nara Sumber /Pembicara : 1) ................................................................
 /Undangan Eksternal : 2) ................................................................
: 3) ................................................................
3.6. Deskripsi Singkat Kegiatan : .................................................................
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3.7. Foto dan Dokumentasi Kegiatan di lampirkan
4. KEGIATAN SOSMAS & KEPEMUDAAN BULAN OKTOBER - DESEMBER
4.1. Nama Kegiatan/Acara : .....................................................................
4.2. Nomor SK Panitia : …………………….……………………………(SK dilampirkan)
4.3. Tgl dan waktu Kegiatan : .....................................................................
4.4. Jumlah Peserta : .............. Orang (Absen dilampirkan)
4.5. Nara Sumber /Pembicara : 1) ................................................................
/Undangan Eksternal : 2) ................................................................
: 3) ................................................................
4.6. Deskripsi Singkat Kegiatan : .................................................................
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4.7. Foto dan Dokumentasi Kegiatan di lampirkan
VII. KAPASITAS DIGITAL KADER
LEGALITAS
1. SK Tim Cyber
2. Memiliki 4 akun Medsos
3. Follower
4. Jumlah kader pelatihan cyber (dibuktikan sertifikat)
VIII. KONSOLIDASI ORGANISASI
1. RAPAT KERJA (SATU TAHUN SEKALI)
a. SK Panitia Raker
b. Undangan
c. Daftar Hadir
d. Dokumentasi Kegiatan Raker
2. RAPAT PENGURUS HARIAN PAC (SETIAP 1 BULAN SEKALI)
a. Undangan
b. Notulensi Rapat
c. Daftar Hadir
d. Dokumentasi Kegiatan
IX. AMAL USAHA
1. SK
2. Badan Hukum,
3. 1 Koperasi/LKMS (Lembaga Keuangan Mikro Syaria) dan/ 1 LKP & 1 LUP
4. Laporan Keuangan