BUKU

WEJANGAN & TANDA TANGAN

RANTING PAKUSARI

Untuk Siswa ijo

Jer Basuki Mawa Beya

(Segala Kesuksesan Membutuhkan Pengorbanan)

Nama : ……………………………………………….

Rayon/Ranting : ……………………………………………….
 PENGURUS RANTING
PERSAUDARAAN SETIA HATI TERATE
RANTING PAKUSARI – CABANG JEMBER
PUSAT MADIUN - INDONESIA
KEMENHUMHAM RI : IDM 000142231 DAN IDM 000142233
Sekretariat : Jl. PB Sudirman No. 16. Pakusari, Jember, 68181, Telp 082323413460

BIODATA SISWA HIJAU

NAMA : ............................................................................................................

RAYON : ............................................................................................................

RANTING : ............................................................................................................

ALAMAT : ............................................................................................................

PELATIH TETAP : ............................................................................................................

NO. HP : ............................................................................................................

STATUS : ............................................................................................................

Pakusari, 10 Januari 2024

Ketua Ranting Pakusari

Icuk Darmawan A. J, S.Pd

NIW. 11 025 0115
 PENGURUS RANTING
PERSAUDARAAN SETIA HATI TERATE
RANTING PAKUSARI – CABANG JEMBER
PUSAT MADIUN - INDONESIA
KEMENHUMHAM RI : IDM 000142231 DAN IDM 000142233
Sekretariat : Jl. PB Sudirman No. 16. Pakusari, Jember, 68181, Telp 082323413460

Nama : ...................................................................... Pengesahan Tahun : .........................................

Alamat : ...................................................................... Jabatan : .........................................

MATERI KE SH-AN
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Jember, .......................................2024
TTD Warga

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