FORMULIR CALON KETUA

RANTING PESANGGRAHAN

Nomor KTA :
Nomor NIK. KTP/KK : ..........................................................................................................................................
Nama Lengkap : .........................................................................................................................................
Tempat/Tgl. Lahir : .........................................................................................................................................
Provinsi : .........................................................................................................................................
Kabupaten : .........................................................................................................................................
Kecamatan : .........................................................................................................................................
Kelurahan : .........................................................................................................................................
Alamat Lengkap : ................................................................................. RT/RW : ......................... NO : .......
Telp./HP : .........................................................................................................................................
E- mail : .........................................................................................................................................
Anak Ke : .........................................................................................................................................
Jenis Kelamin : .........................................................................................................................................
Agama : .........................................................................................................................................
Status Perkawinan : .........................................................................................................................................
Pekerjaan : .........................................................................................................................................
Pendidikan Terakhir : .........................................................................................................................................
Suku Bangsa : .........................................................................................................................................
Dengan ini menyatakan bahwa saya bersedia mematuhi dan mentaati Anggaran Dasar/Anggaran Rumah Tangga
(AD/ART) Ormas PEMUDA PANCASILA, Peraturan Organisasi (PO) serta keputusan – keputusan lainya yang
ditetapkan oleh Ormas PEMUDA PANCASILA, dan saya siap dikenakan sanksi organisasi apabila dikemudian hari
saya melakukan hal-hal yang merugikan nama Ormas PEMUDA PANCASILA.
Hormat saya,
Jakarta, .............................................. 20 .....
Yang mengajukan,

( ............................................................. )
Nama Jelas dan Tanda Tangan

Mengetahui,

Pimpinan Anak Cabang,

( .............................................................. )
Ketua

C a t a t a n : 1. Harus diisi dengan huruf kapital dengan jelas.

2. Melampirkan foto kopi KTP ( 1 lembar ).
3. Ditanda tangani dan di stempel oleh masing - masing pimpinan.
4. Formulir yang tidak lengkap tidak dapat di input.
 VISI DAN MISI

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