FORMULIR PENDAFTARAN

PESERTA APRESIASI DUTA GENRE

KABUPATEN SIJUNJUNG TAHUN 2023

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

Nama Panggilan :...........................................................
Tempat/Tanggal Lahir :...........................................................
Jenis kelamin : Laki-laki /Perempuna ( coret yang tidak perlu )
Alamat :...........................................................
No HP/WA :...........................................................
Alamat E-mail :...........................................................
Akun Instagram :...........................................................
Nama Kelompok PIK R :...........................................................
Jalur Pendidikan
Sekolah/Kelas/Univ/Semeter :...........................................................
Alamat Sekolah/Univ :...........................................................
Jalur Masyarakat
Nagari :............................................................
Kecamatam :............................................................
Pengalaman Organisasi :. 1...........................................................
2...........................................................
3...........................................................
Penghargaan / Sertifikat : 1...........................................................
2...........................................................
3...........................................................( boleh lebih )
Catatan Bakat/Minat :
1..............................................................................................................
2..............................................................................................................

Mengetahui,
Kepala Sekolah / Walinagari ........................................2023

(..........................................) (............................................)

Formulir Apresiasi Dugen 2023