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INKAI

INSTITUT KARATE-DO INDONESIA


RANTING MODOLANG KARATE CLUB
SIDOARJO
Sekretariat : Perum Sidokare Asri A. IV/17 Sidoarjo Telp. 089675893816/081230958331

FORMULIR PENDAFTARAN UJIAN

Nama : .........................................................................................

Tempat/Tanggal lahir : .........................................................................................

Sabuk/ Kyu : .........................................................................................

Hasil Ujian Semester : …... / Tahun …..

Agama : .........................................................................................

Nama Orang Tua : .........................................................................................

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

Pekerjaan : .........................................................................................

No. Telepon : .........................................................................................

Mengetahui Sidoarjo, ............ 2022

Nama Orang Tua 4 x 6 = 2 lbr Peserta Ujian


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