PW GP ANSOR JAWA TIMUR

BORANG AKREDITASI PIMPINAN RANTING (PR)

Pimpinan Anak Cabang : Mancengan Kecamatan Modung

Pimpinan Ranting : Brakas Dajah

I. STRUKTUR KEPENGURUSAN PIMPINAN RANTING (PR)

1. Nomor SK : 022/PC/SK-01/IV/2017 (SK dilampirkan)

2. Masa Bhakti : 2017-2019
3. Biodata Pengurus dilampirkan
4. Sertifikat Kaderisasi Pengurus (ketua, Sekretaris, Bendahara & Satkokel) dilampirkan

II. MAJELIS DZIKIR DAN SHOLAWAT RIJALUL ANSOR (MDS RA)

1. Nomor SK: …………………….…………………………… (SK dilampirkan)

2. Kegiatan Bulan Januari Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)
2.1 Tgl dan waktu Kegiatan : .....................................................................
2.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
2.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
2.4 Deskripsi Singkat Kegiatan : .....................................................................................................
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2.5 Foto dan Dokumentasi Kegiatan di lampirkan

3. Kegiatan Bulan Februari Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

3.1 Tgl dan waktu Kegiatan : .....................................................................
3.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
3.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
3.4 Deskripsi Singkat Kegiatan : .................................................................
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3.5 Foto dan Dokumentasi Kegiatan di lampirkan
4. Kegiatan Bulan Maret Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)
4.1 Tgl dan waktu Kegiatan : .....................................................................
4.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
4.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
4.4 Deskripsi Singkat Kegiatan : .................................................................
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4.5 Foto dan Dokumentasi Kegiatan di lampirkan

5. Kegiatan Bulan April Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

5.1 Tgl dan waktu Kegiatan : .....................................................................
5.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
5.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
5.4 Deskripsi Singkat Kegiatan : .................................................................
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................................................................................................................
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5.5 Foto dan Dokumentasi Kegiatan di lampirkan

6. Kegiatan Bulan Mei Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

6.1 Tgl dan waktu Kegiatan : .....................................................................
6.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
6.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
6.4 Deskripsi Singkat Kegiatan : .................................................................
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 6.5 Foto dan Dokumentasi Kegiatan di lampirkan

7. Kegiatan Bulan Juni Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

7.1 Tgl dan waktu Kegiatan : .....................................................................
7.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
7.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
7.4 Deskripsi Singkat Kegiatan : .................................................................
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7.5 Foto dan Dokumentasi Kegiatan di lampirkan

8. Kegiatan Bulan Juli Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

8.1 Tgl dan waktu Kegiatan : .....................................................................
8.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
8.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
8.4 Deskripsi Singkat Kegiatan : .................................................................
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8.5 Foto dan Dokumentasi Kegiatan di lampirkan

9. Kegiatan Bulan Agustus Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

9.1 Tgl dan waktu Kegiatan : .....................................................................
9.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
9.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
9.4 Deskripsi Singkat Kegiatan : .................................................................
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9.5 Foto dan Dokumentasi Kegiatan di lampirkan

10. Kegiatan Bulan September Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

10.1 Tgl dan waktu Kegiatan : .....................................................................
10.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
10.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
10.4 Deskripsi Singkat Kegiatan : .................................................................
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10.5 Foto dan Dokumentasi Kegiatan di lampirkan

11. Kegiatan Bulan Oktober Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

11.1 Tgl dan waktu Kegiatan : .....................................................................
11.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
11.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
11.4 Deskripsi Singkat Kegiatan : .................................................................
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11.5 Foto dan Dokumentasi Kegiatan di lampirkan

12. Kegiatan Bulan November Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

12.1 Tgl dan waktu Kegiatan : .....................................................................
.
12.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
.
12.3 Kyai/Ulama/Habaib : 1) ................................................................
. yang di undang
: 2) ................................................................
: 3) ................................................................
 12.4 Deskripsi Singkat Kegiatan : .................................................................
. ................................................................................................................
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12.5 Foto dan Dokumentasi Kegiatan di lampirkan
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13. Kegiatan Bulan Desember Tahun ........ : ………....................................... ( Nama Acara/Kegiatan)

13.1 Tgl dan waktu Kegiatan : .....................................................................
.
13.2 Jumlah Peserta : .............. Orang (Absen dilampirkan)
.
13.3 Kyai/Ulama/Habaib : 1) ................................................................
. yang di undang
: 2) ................................................................
: 3) ................................................................
13.4 Deskripsi Singkat Kegiatan : .................................................................
. ................................................................................................................
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13.5 Foto dan Dokumentasi Kegiatan di lampirkan
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III. BARISAN ANSOR SERBAGUNA (BANSER)

1. Nomor SK : …………………….…………………………… (SK SATKORKEL dilampirkan)

1. Jumlah Anggota : ……………. Personil (biodata/KTA anggota dilampirkan)
1
1. Photo dan dokumentasi kegiatan dilampirkan
2

2. Unit Khusus Banser ........................................................

2.1. Nomor SK : …………………….…………………………… (SK dilampirkan)
2.2. Jumlah Anggota : ……………. Personil (biodata/KTA anggota dilampirkan)
2.3. Photo dan dokumentasi kegiatan dilampirkan
IV.MEMBINA ANGGOTA BERBASIS MASJID/MUSHOLLAH

1 Jumlah Masjid/Mushollah: …………………………………………………………………………………….

.
1.1. Masjid : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.2. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.3. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.4. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.5. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.6. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.7. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)

V. KEGIATAN SOSIAL KEMASYARAKATAN & KEPEMUDAAN

1. KEGIATAN SOSMAS & KEPEMUDAAN

1.1. Nama Kegiatan/Acara : .....................................................................
1.2. Nomor SK Panitia : …………………….……………………………(SK dilampirkan)
1.3. Tgl dan waktu Kegiatan : .....................................................................
1.4. Jumlah Peserta : .............. Orang (Absen dilampirkan)
1.5. Nara Sumber /Pembicara : 1) ................................................................
/Undangan Eksternal : 2) ................................................................
: 3) ................................................................
1.6. Deskripsi Singkat Kegiatan : .................................................................
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1.7. Foto dan Dokumentasi Kegiatan di lampirkan

2. KEGIATAN SOSMAS & KEPEMUDAAN

2.1. Nama Kegiatan/Acara : .....................................................................
2.2. Nomor SK Panitia : …………………….……………………………(SK dilampirkan)
2.3. Tgl dan waktu Kegiatan : .....................................................................
2.4. Jumlah Peserta : .............. Orang (Absen dilampirkan)
2.5. Nara Sumber /Pembicara : 1) ................................................................
/Undangan Eksternal : 2) ................................................................
: 3) ................................................................
2.6. Deskripsi Singkat Kegiatan : .................................................................
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2.7. Foto dan Dokumentasi Kegiatan di lampirkan