GUGUS DEPAN KOTA SERANG 01.372 BERPANGKALAN PADA UNIVERSITAS PRIMAGRAHA Komplek Grya Gemilang Sakti, Jl. Trip Jamaksari Blok A1 No. 1A, Kaligandu Kec. Serang, Kota Serang, Banten 42111
FORMULIR PENDAFTARAN KEMAH MASA ORIENTASI TAMU RACANA (KEMORA) 4 TAHUN 2023
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Nama Panggilan : .................................................................. Jenis Kelamin : .................................................................. Tempat, Tgl Lahir : .................................................................. Pas Photo Agama : .................................................................. 4x6 Hp : .................................................................. E-Mail : .................................................................. Program Studi : .................................................................. NIM : .................................................................. Sosial Media :Instagram: ....................................................................................... Facebook: ........................................................................................ Golongan Pramuka : ........................................................................................................ Alamat Identitas : ........................................................................................................ ........................................................................................................ Alamat Saat Ini : Isikan Jika Tempat Tinggal Anda Saat Ini (Kost/Asrama/Mes/Pondok Pesantren) ........................................................................................................ ........................................................................................................
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Motivasi Mengikuti KEMORA 4 : ....................................................................................... ............................................................................................................................................... ...............................................................................................................................................