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KELOMPOK BELAJAR

DARURROHMAH
Cibeureum II RT 02/RW 04 Kel. Sukalaksana Kec. Bungursari Kota Tasikmalaya46151
Email: darurohmahkb@gmail.comNo. HP. 082317300868

No. Pendaftaran : ……….

FORMULIR PENDAFTARAN

1. SANTRI / SISWA/SISWI
Nama Lengkap :......................................................................
Nama Panggilan :......................................................................
No. NIK :......................................................................
No. Akta Lahir :......................................................................
Jenis Kelamin :......................................................................
Tempat dan Tanggal Lahir :......................................................................
Anak Ke :......................................................................
Alamat :......................................................................
:......................................................................
Telepon/HP :......................................................................
Tinggi Badan :……………………………………………..
Berat Badan :……………………………………………..
Diterima di
a. Di kelas/Kelompok :......................................................................
b. Pada Tanggal :......................................................................

2. ORANG TUA / WALI


Nama Orangtua
a. Ayah :......................................................................
b. Ibu :......................................................................
Alamat Orangtua :......................................................................
:......................................................................
No KTP/NIK Ayah :……………………………………………..
No KTP/NIK Ibu :…………………………………………….
Telepon / Hp :......................................................................
Pekerjaan Orangtua
a. Ayah :......................................................................
b. Ibu :......................................................................
Nama Wali :......................................................................
Pekerjaan Wali :......................................................................
Alamat Wali :......................................................................
.......................................................................
Telepon / Hp :......................................................................

Kelengkapan Administrasi :
- Photocopi Kartu Keluarga
- Photocopi Akta Lahir
- Photocopi KTP Ayah – Ibu
- Photocopi Kartu PKH/KIS/KKS/semacamnya

Tasikmalaya, ………………………

…………………………………
KELOMPOK BELAJAR
DARURROHMAH
Cibeureum II RT 02/RW 04 Kel. Sukalaksana Kec. Bungursari Kota Tasikmalaya46151
Email: darurohmahkb@gmail.comNo. HP. 082317300868

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