KELUARGA PENCAK SILAT NUSANTARA

KPSN
Alamat : Jl. Raya Palu- Km. 14 Kode Pos 94364

FORMULIR PENDAFTARAN

Nama Lengkap : ........................................................................................................

Jenis Kelamin : ☐ Pria ☐Wanita

Tempat, Tanggal Lahir : ........................................................................................................

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Agama :☐ Islam ☐ Protestan ☐ Katolik

☐ Hindu ☐ Buddha ☐ Khonghucu

Asal Sekolah : ........................................................................................................

Alamat : ........................................................................................................

RT : ....................................... RW : .............................................

Desa/Kelurahan : ...........................................................................

Kecamatan :...................................................................................

Kota/Kabupaten : ..........................................................................

Pernah Ikut Beladiri ? : ☐ Ya ☐ Tidak

No. WhatsApp : ........................................................................................................

Alasan Masuk KPSN : ........................................................................................................

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Sidera, .../.../2022
Pendaftar

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