LPPTKA BKPRMI KOTA PALEMBANG

Sekretariatan : Jalan Angkatan 45 Lr. Harapan Baru

No.3005 HP.085279780771

DATA PESERTA MUNAQOSAH GELOMBANG KE

TANGGAL

Nama Unit :................................................

No.Unit :................................................
Kepala Unit :................................................
Kecamatan :................................................
Jumlah Peserta : LK :......PR :..........Total :.........

Tempel Fhoto
Nama Santri :..........................................................................
Jenis Kelamin :..........................................................................
NIS :..........................................................................
Tempat/Tgl Lahir :..........................................................................
Alamat :..........................................................................
Nama Ayah :..........................................................................
Nama Ibu :..........................................................................

Nama Santri :..........................................................................

Jenis Kelamin :..........................................................................
NIS :..........................................................................
Tempat/Tgl Lahir :..........................................................................
Alamat :..........................................................................
Nama Ayah :..........................................................................
Nama Ibu :..........................................................................

Nama Santri :..........................................................................

Jenis Kelamin :..........................................................................
NIS :..........................................................................
Tempat/Tgl Lahir :..........................................................................
Alamat :..........................................................................
Nama Ayah :..........................................................................
Nama Ibu :..........................................................................

Syarat yang wajib dikumpulkan

* Fhoto warna Layar merah 3X4 = 3 Lembar
* Fhoto Kopy Akte Kelahiran 1 Lembar
Catatan :
Semua berkas dimasukkan dalam SATU MAP Kambing warna Merah
* formulir bisa diperbanyak