Anak-Anak Terang (AAT)

Beasiswa dan Pendampingan

www.sianas.aat.or.id

Sekolah dan Penanggung Jawab (PJ)

1. Data Komunitas/Sekolah

Nama Komunitas/Sekolah : ..........................................………………………………………..........

Alamat Komunitas/Sekolah : ..........................................………………………………………..........
No. Telp. : ..........................................………………………………………..........
No. Fax. : ..........................................………………………………………..........
Email : ..........................................………………………………………..........

2. Data Penanggung Jawab Baru (PJ)

Nama Lengkap : ..........................................………………………………………..........

Pekerjaan : ..........................................………………………………………..........
Jabatan : ..........................................………………………………………..........
Agama** : ISLAM / KRISTEN / KATHOLIK / HINDU / BUDHA / _________
No. HP. : ..........................................………………………………………..........
Email : ..........................................………………………………………..........
Nama Instansi : ..........................................………………………………………..........
Alamat Kantor : ..........................................………………………………………..........
No. Telp. Kantor : ..........................................………………………………………..........
No. Fax. Kantor : ..........................................………………………………………..........
Alamat Rumah : ..........................................………………………………………..........
No. Telp. Rumah : ..........................................………………………………………..........
**) coret yang tidak perlu

Pimpinan/Kepala Sekolah, Penanggung Jawab (PJ),

( …………………………….………………. ) ( …………………………….………………. )