Diterima di Lembaga :
a. Pada Tanggal............................................................................................
b. Jenjang/jilid.............................................................................................
Ayah/ wali
Nama :.........................................................................................
Agama :.........................................................................................
Pekerjaan :.........................................................................................
Pendidikan :.........................................................................................
IBU
Nama :.........................................................................................
Agama :.........................................................................................
Pekerjaan :.........................................................................................
Pendidikan :.........................................................................................
3x4