PANITIA PELAKSANA

GENGGELANG CUP 2023

Sekertariat Jalan Air Terjun Kerta Gangga Desa Genggelang Kecamata Gangga Kabupaten Lombok Utara

DAFTAR NAMA PEMAIN

NAMA CLUB/KESEBELASAN : .....................................................................................................

ALAMAT CLUB/KESEBELASAN : ..................................................................................................…

1. Nama : ............................................................ 2. Nama : ............................................................

Alamat : ............................................................ Alamat : ............................................................

Umur : ............................................................ Umur : ............................................................

Posisi : ............................................................. Posisi : .............................................................

No Pgng : ............................................................ No Pgng : ............................................................

Phas foto Phas foto

3x4 3x4

3. Nama : ............................................................ 4. Nama : ............................................................

Alamat : ............................................................ Alamat : ............................................................

Umur : ............................................................ Umur : ............................................................

Posisi : ............................................................. Posisi : .............................................................

No Pgng : ............................................................ No Pgng : ............................................................

Phas foto Phas foto

3x4 3x4

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

5. Nama : ............................................................ 6. Nama : ............................................................

Alamat : ............................................................ Alamat : ............................................................

Umur : ............................................................ Umur : ............................................................

Posisi : ............................................................. Posisi : .............................................................

No Pgng : ............................................................ No Pgng : ............................................................

Phas foto Phas foto

3x4 3x4

7. Nama : ............................................................ 8. Nama : ............................................................

Alamat : ............................................................ Alamat : ............................................................

Umur : ............................................................ Umur : ............................................................

Posisi : ............................................................. Posisi : .............................................................

No Pgng : ............................................................ No Pgng : ............................................................

Phas foto Phas foto

3x4 3x4

9. Nama : ............................................................ 10. Nama :.............................................................

Alamat : ............................................................ Alamat : ............................................................

Umur : ............................................................ Umur : ............................................................

Posisi : ............................................................. Posisi : .............................................................

No Pgng : ............................................................ No Pgng : ............................................................

Phas foto Phas foto

3x4 3x4

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

 11. Nama : ................................................... 12. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

13. Nama : ................................................... 14. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

15. Nama : ................................................... 16. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

17. Nama : ................................................... 18. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

19. Nama : ................................................... 20. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

21. Nama : ................................................... 22. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

23. Nama : ................................................... 24. Nama : ...................................................

Alamat : ................................................. Alamat : .................................................

Umur ................................................... Umur ...................................................

Posisi : .................................................. Posisi : ..................................................

No Pgng : ............................................... No Pgng : ...............................................

Phas foto Phas foto

3x4 3x4

25. Nama : ...................................................

Alamat : .................................................

Umur ...................................................

Posisi : ..................................................

No Pgng : ...............................................

Phas foto

3x4

Dibuat oleh Diverifikasi oleh

Manager Klub Panitia Pelaksana Genggelang Cup 2023

(.………………………………..) (.………………………………………)

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

 PANITIA PELAKSANA
GENGGELANG CUP 2023
Sekertariat Jalan Air Terjun Kerta Gangga Desa Genggelang Kecamata Gangga Kabupaten Lombok Utara

DAFTAR NAMA OFFICIAL CLUB DAN KOSTUM

NAMA CLUB/KESEBELASAN : .....................................................................................................

ALAMAT CLUB/KESEBELASAN : ..................................................................................................…

1. Nama : .......................................................... 2. Nama : ............................................................

Alamat : ............................................................ Alamat : ............................................................

Jabatan : Manager Klub Posisi : Pelatih

Phas foto Phas foto

3x4 3x4

3. Nama : ........................................................ 4. Nama : ............................................................

Alamat : ............................................................ Alamat : ............................................................

Posisi : Tim Medis Posisi : Official Club (Isi sesuai Jabatan)

Phas foto Phas foto

3x4 3x4

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP

5. Nama : ........................................................

Alamat : ............................................................

Posisi : .Official Club (Isi sesuai Jabatan)

Phas foto

3x4

WARNA KOSTUM CLUB :

KOSTUM HOME AWAY

1. JERSEY PEMAIN

2. JERSEY KIPER

3. CELANA

4. KAOS KAKI

Dibuat oleh Diverifikasi oleh

Manager Klub Panitia Pelaksana Genggelang Cup 2023

(.………………………………..) (.………………………………………)

Mohon diisi sesuai dengan KTP dan Lampirkan Fotocopy KTP