085753652338

Muhammad Farid Ridho

3188/PSB/IV/23
PERWAKILAN : KALIMANTAN BARAT

No. NISN : ................................................

0033462148 Nama : ..........................................................
H Syamsul Bahri S Ag M Si
No. KTP / NIK : ................................................
6171050709030004 No. KTP / NIK : ..........................................................
6171051210700008
Tempat Lahir : ................................................
Ngabang No. KK : ..........................................................
6171050102080018
Tanggal Lahir : ................................................
07 / 09 / 2003 Email : ..........................................................
saja81713@gmail.com
Jenis Kelamin : ................................................
Laki-Laki
Anak ke : ................................................
2 dari 4 bersaudara
Saudara di Dalwa : ................................................
2 Laki-Laki Perempuan
Asal Pondok / : MA N 2 Pontianak
Sekolah Umum ........................................................
Kelas : Lulus 12 MA
........................................................
Alamat : Kota Pontinak
........................................................

Jl DR Wahidin S , Komp Sepakai Damai Blok G 6 Riwayat : Tidak Ada

Kesehatan ........................................................
RT.2 / RW.28 - Kel.Sungaijawi, Kec.Pontianak Kota
Kota Pontianak - Kalimantan Barat Alergi Obat : Tidak Ada
.........................................................
Kode Pos 78118
 3188/PSB/IV/23

Muhammad Farid Ridho

Ngabang

07 / 09 / 2003

Jl DR Wahidin S Komp Sepakai Damai Blok G 6

RT.2 / RW.28
Kel. Sungaijawi Pontianak Kota
Kota Pontianak
Kalimantan Barat

H Syamsul Bahri S Ag M Si

085753652338

saja81713@gmail.com

Jl DR Wahidin S Komp Sepakai Damai Blok G 6

Kota Pontianak
Kalimantan Barat

31 / 07 / 2023
................................,........................
Yang Menyatakan Mengetahui
Orang Tua / Wali Calon Santri Pengurus / Perwakilan Pondok

materai 10.000

H Syamsul Bahri S Ag M Si Muhammad Farid Ridho

................................. ................................. .................................
 : 3188/PSB/IV/23
: Muhammad Farid Ridho
: Ngabang , 07 / 09 / 2003
: H Syamsul Bahri S Ag M Si
: 085753652338
: Jl DR Wahidin S , Komp Sepakai Damai Blok G 6 RT.2/RW.28
Kel.Sungaijawi, Kec.Pontianak Kota
Kota Pontianak - Kalimantan Barat

31 / 07 / 2023
................................,........................
Yang Menyatakan Mengetahui
Orang Tua / Wali Calon Santri Pengurus / Perwakilan Pondok

materai 10.000

H Syamsul Bahri S Ag M Si
................................. Muhammad Farid Ridho
................................. .................................
Nomor Pendaftaran : 3188/PSB/IV/23
..........................................................................................
Tanggal Pendaftaran : 31 / 07 / 2023
..........................................................................................
Jurusan : Pendidikan Agama Islam
..........................................................................................
Nama : Muhammad Farid Ridho
..........................................................................................
No. KTP / NIK : 6171050709030004
..........................................................................................
No. Induk Sekolah / NISN : 0033462148
..........................................................................................
No. KK : 6171050102080018
..........................................................................................
Tempat, Tanggal Lahir : Ngabang , 07/09/2003
..........................................................................................
Jenis Kelamin : Laki-Laki
..........................................................................................
Nama Ortu / Wali : H Syamsul Bahri S Ag M Si
..........................................................................................
NIK Ortu / Wali : 6171051210700008
..........................................................................................
Jumlah Saudara : 4 Anak ke : 2
..........................................................................................
Saudara di dalwa : Laki-laki : Orang, Perempuan : Orang
..........................................................................................
No. Kontak Ortu / Wali : 085753652338
..........................................................................................
Email Ortu / Wali : ..........................................................................................
saja81713@gmail.com
Alamat : Jl DR Wahidin S , Komp Sepakai Damai Blok G 6
..........................................................................................
RT.2/RW.28, Kel.Sungaijawi, Kec.Pontianak Kota
..........................................................................................
Kota Pontianak - Kalimantan Barat
..........................................................................................
Kode POS : 78118
..........................................................................................

Asal Sekolah / Pondok : MA N 2 Pontianak

..........................................................................................
Alamat Sekolah / Pondok : Kota Pontinak
..........................................................................................
Kelas : 12 MA
..........................................................................................

Riwayat Penyakit : tidak ada

..........................................................................................
Alergi Obat : tidak ada
..........................................................................................

31 / 07 / 2023
................................,........................
Nama Calon Siswa

Muhammad Farid Ridho

.................................