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FORMULIR PENDAFTARAN CALON MAHASANTRI

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

2. Nama Ayah : ................................................................................................................................

3. Nama Ibu : ................................................................................................................................

4. Tempat/Tanggal Lahir : ................................................................................................................................

: No Induk Warga : ........................................................................................


5. Kartu Pribadi
No Induk Santri : ........................................................................................

6. Jenis Kelamin :  LK  PR Suku Bangsa : ...........................................................

Golongan Darah : ................................... Berat Badan : .....


7. Kesehatan : Penyakit Yang Pernah diderita : ................................... Tinggi : .....
Penanganan : ...................................

8. Pekerjaan Ayah : ...............................................................................................................................

9. Pekerjaan Ibu : ...............................................................................................................................

No : .......... Rt : ........... Rw : ......... Kp : ...........................................


Kel : ................................... Kec : ...........................................
10. Alamat Lengkap :
Kab : ................................... Prov : ...........................................
Kode Post : ................................... Hp : ...........................................

11. Pendidikan Terakhir :  Madrasah Khalifah Abu Bakar Ash Shiddiq


Keterangan : ..........................................................................................................

12. Administrasi : Photo Copy Raport Terakhir  3 Rangkap

Margodadi , .......... Syawwal 1444 H

Calon Mahasantri

.......................................

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