PONDOK PESANTREN

“MIFTAHUL INAYAH”
Jl Raya Lakbok KM.03 RT. 18 RW. 05 Desa Sindanghayu Kecam-.atan Banjarsari Kabupaten Ciamis

FORMULIR PENDAFTARAN SANTRI / SANTRIAH BARU

NO. REGISTRASI : ........../PSB.PK-PPMFI/........../20......../14........

1. IDENTITAS SANTRI BARU
NAMA LENGKAP : .......................................................................................................................
TTL : .......................................................................................................................
JENIS KELAMIN : LAKI-LAKI / PEREMPUAN *coret yang tidak perlu
ANAK KE : .......... DARI .......... BERSAUDARA.
ALAMAT : .......................................................................................................................
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2. ASAL SEKOLAH / MADRASAH
NAMA SEKOLAH/MADRASAH : ...............................................................................................
ALAMAT SEKOLAH/MADRASAH : ...............................................................................................
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3. IDENTITAS ORANG TUA / WALI
NAMA AYAH : .....................................................................................................................
NAMA IBU : .....................................................................................................................
ALAMAT : ...........................................................................................................
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PEKERJAAN AYAH : ...........................................................................................................
PEKERJAAN IBU : ...........................................................................................................
NO TELP. : ...........................................................................................................
4. ADMINISTRASI - UANG MIFTAH : RP. ....................................................
- SYAHRIAH : RP. ....................................................
- BERAS : RP. .............................. / ............ KG
- LAUK PAUK : RP. ....................................................
JUMLAH : RP. ....................................................

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MENGETAHUI

ORANG TUA CALON SANTRI

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