YAYASAN MIZAN AMAL

Akte Notaris: ONY SEPTI PONTUANTO, S.H. Nomor 71/28-II/2013

SK KEMENKUMHAM RI Nomor: AHU-1781.AH.01.04. Tahun 2013
Kantor Cabang: Kaplingan Sukci, RT04, RW03,Sukci, Bulusari, Gempol, Pasuruan
Telp. 0895-3411-21164, 0852-3492-3207

FORMULIR PENDAFTARAN BEASISWA

PENDIDIKAN YATIM / PIATU 3x4

No:

Data Pribadi Penerima Beasiswa

1. Nama Lengkap : ................................................................................................................
2. Nama Panggil : ................................................................................................................
3. Jenis Kelamin : ................................................................................................................
4. Tempat Lahir : ................................................................................................................
5. Tanggal Lahir : ................................................................................................................
6. Usia : ................................................................................................................
7. Alamat Lengkap : ................................................................................................................
: ................................................................................................................
8. Nomor HP/WA : ................................................................................................................
9. Nama Sekolah : ................................................................................................................
10. Warga Negara : ................................................................................................................
11.Kelainan Jasmani : ................................................................................................................
12.Penyakit Berat : ................................................................................................................
13.Tinggi/Berat Badan : ................................................................................................................
14.Prestasi : 1).............................................................................................................
: 2).............................................................................................................
: 3) ............................................................................................................
15.Hobi : ................................................................................................................
16.Bakat Ketrampilan : ................................................................................................................
17.Cita-cita : ................................................................................................................
Data Orangtua/Wali Penerima beasiswa
A. Ayah Kandung/Wali
Nama Lengkap : ................................................................................................................
TTL : ................................................................................................................
Agama : ................................................................................................................
Pendidikan : ................................................................................................................
Pekerjaan : ................................................................................................................
Warga Negara : ................................................................................................................
No HP/WA : ................................................................................................................
B. Ibu Kandung
Nama Lengkap : ................................................................................................................
TTL : ................................................................................................................
Agama : ................................................................................................................
Pendidikan : ................................................................................................................
Pekerjaan : ................................................................................................................
Warga Negara : ................................................................................................................
No HP/WA : ................................................................................................................
 YAYASAN MIZAN AMAL
Akte Notaris: ONY SEPTI PONTUANTO, S.H. Nomor 71/28-II/2013
SK KEMENKUMHAM RI Nomor: AHU-1781.AH.01.04. Tahun 2013
Kantor Cabang: Kaplingan Sukci, RT04, RW03,Sukci, Bulusari, Gempol, Pasuruan
Telp. 0895-3411-21164, 0852-3492-3207

BERKAS YANG DISERAHKAN

TANDA TERIMA BERKAS

Berilah tanda checklist data yang sudah diserahkan !

Telah menyerahkan map beserta fotocopy lampiran tersebut di atas :

1) Foto Copy Akta Kelahiran 2 rangkap [ ]

2) Foto Copy Kartu Keluarga 2 rangkap [ ]
3) Foto Copy KTP Orantua (Ayah dan Ibu) 2 rangkap [ ]
4) Pas Foto 2x3, 3x4 dan 4x6 (wajib berhijab bagi Akhwat ) masing-masing 3 [ ]
lembar
5) Foto Copy Rapot Terakhir [ ]
6) Foto Copy Surat Keterangan Kematian [ ]

Mengetahui Sidoarjo,........../........../2022
Front Officer Wali Penerima Beasiswa
Mizan Amal

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