FORMULIR PERMOHONAN PERORANGAN

KOPERASI SYARI'AH ARRAHMAH MARTAPURA

Kantor : Jl. Muslim Komp Sa'adah 3, Gg Muslim Rt 18 Rw 5, Kel/Desa Sei Paring, Kec Martapura (Seberang Masjid Syarifah Shalihah)
Handphone : 082154011112 / WhatsApps 082154011112
E-mail : ksarrahmahmartapura@gmail.com , Web : http://kopsyaharrahmah.co.id, Arrahmah Store : ksarrahmah.store.com

Nomor JCA : ...................................................................................... Cabang : ......................................................................................

Pengajuan : ......................................................................................
DATA PRIBADI PEMOHON
Nama Lengkap : ...................................................................................... Jenis Kelamin : ......................................................................................
Tempat Tanggal Lahir : ................................................................................................... Agama : ......................................................................................
Pendidikan Terakhir : ................................................................................................... E-Mail : ......................................................................................
Nomor KTP : ................................................................................................... NPWP : ......................................................................................
Alamat Sesuai KTP : ...................................................................................................................................................................................................................................

Kabupaten / Kotamadya : ............................................... Kode Pos : ......................................................................................

Nomor Telepon : ................................................................................................... PIN BBM : ......................................................................................
Alamat Saat Ini : ...................................................................................................................................................................................................................................
Kabupaten / Kotamadya : ............................................... Kode Pos : ......................................................................................
Status Rumah : Milik Sendiri Orang Tua / Keluarga Sewa Rumah Dinas
Status : Lajang Menikah Duda / Janda
Nama Orang Tua : ...................................................................................................................................................................................................................................
DATA PEKERJAAN / USAHA
Nama Instansi/Perusahaan : ................................................................................................... Lama Bekerja : ............ tahun
Jabatan : ................................................................................................... Nama Atasan Langsung : ......................................................................................
Alamat Kantor : ...................................................................................................................................................................................................................................
Nomor Telepon : ................................................................................................... Ext./Pswt ...............Fax : ......................................................................................
Status : PNS Swasta Wiraswasta Lainnya

DATA PENGHASILAN (PER BULAN)

Penghasilan Pemohon : Rp. ............................................................................................. Pengeluaran Rutin : Rp. ................................................................................
Penghasilan Tambahan : Rp. ............................................................................................. Angsuran Ditempat Lain : Rp. ................................................................................
Penghasilan Suami / Istri : Rp. .................................................................................................
Jumlah Penghasilan : Rp. ............................................................................................. Sisa Penghasilan : Rp. ................................................................................
Jumlah Tanggungan : ................................. Suami / Istri ............... Anak ................ Lainnya

DATA SUAMI / ISTRI

Nama Lengkap : ................................................................................................... Pekerjaan : ......................................................................................
Nama Instansi/Perusahaan : ................................................................................................... Lama Bekerja : ......................................................................................
Nomor Telepon : ................................................................................................... Ext./Pswt ...............Fax : ......................................................................................

KELUARGA DEKAT YANG BISA DIHUBUNGI (YANG TIDAK SERUMAH)

Nama Lengkap : ................................................................................................... Hubungan : ......................................................................................
Alamat : ................................................................................................... Kode Pos : ......................................................................................
........................................................................................
Nomor Telepon : ................................................................................................... PIN BBM : ......................................................................................

PIHAK KOPERASI YANG DIKENAL

Nama Lengkap : ................................................................................................... Nomor Telepon : ......................................................................................
Nomor KTP : ................................................................................................... Status di Koperasi : Anggota / Karyawan / Pengurus / Pengawas / Pembina
Alamat Lengkap : .......................................................................................................

PENGAJUAN PEMBELIAN BARANG

Nama & Jenis Barang Kemampuan Mengangsur
:.................................................................................................... : Rp. ................................................................................
Harga Barang Jangka Waktu Uang Muka
Rp. ...................................... : ............... (Bulan) : Rp. ................................................................................
AGUNAN
Nama / Jenis Agunan :.................................................................................................... Nilai Jual : Rp. ................................................................................
Tahun :....................................................................................................

REKOMENDASI (ANGGOTA KOPERASI) REKOMENDASI (KELUARGA DEKAT)

Nama Lengkap : ................................................................................................... Nama Lengkap : ......................................................................................
Alamat : ................................................................................................... Alamat : ......................................................................................
........................................................................................ ........................................................................................
Nomor Telepon : ................................................................................................... Nomor Telepon : ......................................................................................

Demikian permohonan ini diajukan, kami menyatakan tunduk pada ketentuan Koperasi KONSUMEN SYARIAH ARRAHMAH termasuk dalam melakukan verifikasi data. Apabila dikemudian hari diketemukan
ketidaksesuaian data maka kami siap diproses sesuai dengan ketentuan hukum yang berlaku.

.............................., Tanggal ................................ TANDA TANGAN

TANDA TANGAN Rekomendasi Rekomendasi
Pemohon Suami / Istri Pemohon

(............................................................) (............................................................) (............................................................) (............................................................)

PERSYARATAN :
1. Anggota Koperasi 7. Fotocopy Rekening Listrik, Air.
2. Pas Foto Terbaru Suami & Istri bagi yang sudah menikah. 8. Slip Gaji atau Fotocopy tabungan 3 bulan terakhir atau rekening koran 3 bulan terakhir.
3. Fotocopy KTP Berwarna Suami & Istri bagi yang sudah menikah. 9. Agunan wajib
4. Fotocopy KTP Rekomendasi. 10. Pengajuan Motor & Mobil Second Wajib Melampirkan Pas Foto, Fotocopy STNK & BPKB.
5. Fotocopy Kartu Keluarga. 11. Bersedia di Survei
6. Gambar Peta lokasi rumah.
Sesuai Peraturan Bank Indonesia No.3/10/PBI/2001 Tanggal 18 Juni 2001 dan No.3/23/PBI/2001 tanggal 13 Desember 2001 tentang Penerapan Prinsip Mengenal Nasabah.
*Pasal 378 KUHP (penipuan) "Barang siapa dengan maksud untuk menguntungkan diri sendiri atau orang lain dengan melawan hukum, dengan memakai nama palsu atau martabat palsu, dengan tipu muslihat ataupun dengan rangkaian kebohongan
menggerakan orang lain untuk menyerahkan sesuatu benda kepadanya, atau supaya memberi hutang maupun menghapuskan piutang, diancam karena penipuan dengan pidana penjara paling larna 4 (empat) tahun".