BORANG AKREDITASI PIMPINAN RANTING

Pimpinan Anak Cabang : ....................................

Pimpinan Ranting : .........................................

I. STRUKTUR KEPENGURUSAN PIMPINAN RANTING (PR)

1. Nomor SK: 007 / 29 /SK / IV 2021 ( pengajuan ) (SKdilampirkan)

3. Biodata Pengurus dilampirkan
4. Sertifikat Kaderisasi Pengurus (ketua, Sekretaris, Bendahara & Satkokel) dilampirkan

II. MAJELIS DZIKIR DAN SHOLAWAT RIJALUL ANSOR (MDS RA)

1. NomorSK:…………………….……………………………002 / SK – RA / 12/ IX / 2021 (SKdilampirkan)

2. Biodata pengurus harian MDS – RA + sertifikat kaderisasi
3. KegiatanBulan Januari Tahun........ :………....................................... ( Nama Acara/Kegiatan)
2.1 TgldanwaktuKegiatan : .....................................................................
2.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
2.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
2.4 Deskripsi Singkat Kegiatan : .....................................................................................................
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2.5 Foto dan Dokumentasi Kegiatan di lampirkan

3. KegiatanBulan Februari Tahun........ :………....................................... ( Nama Acara/Kegiatan)

3.1 TgldanwaktuKegiatan : .....................................................................
3.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
3.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
3.4 Deskripsi Singkat Kegiatan : .................................................................
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3.5 Foto dan Dokumentasi Kegiatan di lampirkan
4. KegiatanBulan Maret Tahun........ :………....................................... ( Nama Acara/Kegiatan)
4.1 TgldanwaktuKegiatan : .....................................................................
4.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
4.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
4.4 Deskripsi Singkat Kegiatan : .................................................................
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4.5 Foto dan Dokumentasi Kegiatan di lampirkan

5. KegiatanBulan April Tahun........ :………....................................... ( Nama Acara/Kegiatan)

5.1 TgldanwaktuKegiatan : .....................................................................
5.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
5.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
5.4 Deskripsi Singkat Kegiatan : .................................................................
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5.5 Foto dan Dokumentasi Kegiatan di lampirkan

6. KegiatanBulan Mei Tahun........ :………....................................... ( Nama Acara/Kegiatan)

6.1 TgldanwaktuKegiatan : .....................................................................
6.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
6.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
6.4 Deskripsi Singkat Kegiatan : .................................................................
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6.5 Foto dan Dokumentasi Kegiatan di lampirkan

7. KegiatanBulan Juni Tahun........ :………....................................... ( Nama Acara/Kegiatan)

7.1 TgldanwaktuKegiatan : .....................................................................
7.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
7.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
7.4 Deskripsi Singkat Kegiatan : .................................................................
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7.5 Foto dan Dokumentasi Kegiatan di lampirkan

8. KegiatanBulan Juli Tahun........ :………....................................... ( Nama Acara/Kegiatan)

8.1 TgldanwaktuKegiatan : .....................................................................
8.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
8.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
8.4 Deskripsi Singkat Kegiatan : .................................................................
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8.5 Foto dan Dokumentasi Kegiatan di lampirkan

9. KegiatanBulan Agustus Tahun........ :………....................................... ( Nama Acara/Kegiatan)

9.1 TgldanwaktuKegiatan : .....................................................................
9.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
9.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
9.4 Deskripsi Singkat Kegiatan : .................................................................
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9.5 Foto dan Dokumentasi Kegiatan di lampirkan

10. KegiatanBulan September Tahun........ :………....................................... ( Nama Acara/Kegiatan)

10.1 TgldanwaktuKegiatan : .....................................................................
10.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
10.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
10.4 Deskripsi Singkat Kegiatan : .................................................................
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10.5 Foto dan Dokumentasi Kegiatan di lampirkan

11. KegiatanBulan Oktober Tahun........ :………....................................... ( Nama Acara/Kegiatan)

11.1 TgldanwaktuKegiatan : .....................................................................
11.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
11.3 Kyai/Ulama/Habaib : 1) ................................................................
yang di undang : 2) ................................................................
: 3) ................................................................
11.4 Deskripsi Singkat Kegiatan : .................................................................
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11.5 Foto dan Dokumentasi Kegiatan di lampirkan

12. KegiatanBulan November Tahun........ :………....................................... ( Nama Acara/Kegiatan)

12.1 TgldanwaktuKegiatan : .....................................................................
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12.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
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12.3 Kyai/Ulama/Habaib : 1) ................................................................
. yang di undang
: 2) ................................................................
 : 3) ................................................................
12.4 Deskripsi Singkat Kegiatan : .................................................................
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12.5 Foto dan Dokumentasi Kegiatan di lampirkan
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13. KegiatanBulan Desember Tahun........ :………....................................... ( Nama Acara/Kegiatan)

13.1 TgldanwaktuKegiatan : .....................................................................
.
13.2 JumlahPeserta : .............. Orang (Absen dilampirkan)
.
13.3 Kyai/Ulama/Habaib : 1) ................................................................
. yang di undang
: 2) ................................................................
: 3) ................................................................
13.4 Deskripsi Singkat Kegiatan : .................................................................
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13.5 Foto dan Dokumentasi Kegiatan di lampirkan
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III. BARISAN ANSOR SERBAGUNA (BANSER)

1. NomorSK:…02/SK banser/12/IX/2021………………….……………………………(SK SATKORKELdilampirkan)

2. Biodata Pengurus Harian + Sertifikat kaderisasi
2. JumlahAnggota :…………….Personil(biodata/KTAanggota dilampirkan)
1

3. Dokumentasi kegiatan

IV. ANGGOTA BERBASIS MASJID/MUSHOLLAH

1 JumlahMasjid/Mushollah:…………………………………………………………………………………….
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1.1. Masjid : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.2. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.3. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.4. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.5. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.6. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)
1.7. Mushollah : .............................................. Jumlah Anggota : ................Orang
(daftar nama dilampirkan)

V. KEGIATAN SOSIAL KEMASYARAKATAN & KEPEMUDAAN

1. KEGIATAN SOSMAS & KEPEMUDAAN

1.1. Nama Kegiatan/Acara : .....................................................................
1.2. NomorSK Panitia :…………………….……………………………(SKdilampirkan)
1.3. TgldanwaktuKegiatan : .....................................................................
1.4. JumlahPeserta : .............. Orang (Absen dilampirkan)
1.5. Nara Sumber /Pembicara : 1) ................................................................
/Undangan Eksternal : 2) ................................................................
: 3) ................................................................
1.6. Deskripsi Singkat Kegiatan : .................................................................
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1.7. Foto dan Dokumentasi Kegiatan di lampirkan

2. KEGIATAN SOSMAS & KEPEMUDAAN

2.1. Nama Kegiatan/Acara
2.2. NomorSK Panitia
2.3. TgldanwaktuKegiatan
2.4. JumlahPeserta
2.5. Nara Sumber /Pembicara
: .....................................................................
:…………………….……………………………(SKdilampirkan)
: .....................................................................
: .............. Orang (Absen dilampirkan)
: 1) ................................................................
 /Undangan Eksternal : 2) ................................................................
: 3) ................................................................
2.6. Deskripsi Singkat Kegiatan : .................................................................
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2.7. Foto dan Dokumentasi Kegiatan di lampirkan