FORMULIR PENDAFTARAN

LOMBA MEWARNAI GAMBAR BERDIMENSI

DALAM RANGKA MEMPERINGATI HARI ANAK NASIONAL 2016

DAN HUT KEMERDEKAAN RI KE 71

RUMAH BUDAYA PUTRI ASIH

NAMA : ...............................................................................................

TTL : ...............................................................................................

ALAMAT : ...............................................................................................

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ASAL SEKOLAH : ...............................................................................................

KATEGORI :SD/MI (kelas 4 s/d kelas 6) - (coret yang tidak perlu)

NO. HP YG DAPAT DIHUBUNGI : .........................................................................................

Tuban, ........................ 2016

GURU PEMBIMBING/ ORANG TUA SISWA

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