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PANITIA

PENDIDIKAN DAN LATIHAN DASAR BANSER


(DIKLATSAR BANSER)
PAC GP ANSOR MENGANTI
XII-02-12 GRESIK XII-02-12

FORMULIR PENDAFTARAN
PESERTA PENDIDIKAN DAN LATIHAN DASAR (DIKLATSAR) BANSER
SATKORYON MENGANTI 2023

Yang bertanda tangan di bawah ini :

Nama Lengkap : ...................................................................................................

Tempat / Tgl. Lahir : ...................................................................................................

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

Status Nikah : ...................................................................................................

Alamat Rumah : ...................................................................................................

No. HP / Telp. : ...................................................................................................

Riwayat Pendidikan Terakhir : ...................................................................................................

Riwayat Organisasi : ...................................................................................................

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Riwayat Pelatihan : ...................................................................................................

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Ukuran Kaos : ...................................................................................................

Mohon di daftar sebagai Peserta Pendidikan dan Latihan Dasar (DIKLATSAR) yang
diselenggarakan oleh PAC. GP. ANSOR Kec. Menganti pada Tanggal 07-09 Juli 2023.

..............................,.................................... 2023
Calon Peserta

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