PENGURUS KOMISARIAT

PERGERAKAN MAHASISWA ISLAM INDONESIA

(Indonesian Moslem Student Movement)
SEKOLAH TINGGI AGAMA ISLAM AL-AZHARY CIANJUR
MASA KHIDMAT 2023-2024
Alamat: Jl. KH Abdullah Bin Nuh Pamoyanan Cianjur Tlp. 0858-1313-9390 e-mail: pmiialazhary@gmail.com

FORMULIR PENDAFTARAN
MASA PENERIMAAN ANGGOTA BARU (MAPABA)
PK. PMII STAI AL-AZHARY CIANJUR

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

TTL : ................................................................................................................................
Alamat : .................................................................................................................................
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Pekerjaan : .................................................................................................................................
Prodi/Jurusan : ................................................................................................................................
No Kontak : ................................................................................................................................

RIWAYAT PENDIDIKAN
1. SD/MI : ......................................................................................Tahun .................................
2. SMP/MTS : ......................................................................................Tahun .................................
3. SMA/MA : ......................................................................................Tahun .................................

Riwayat Organisasi Intra

1. ........................................ sebagai ..........................................................Tahun .................................
2. ........................................ sebagai ..........................................................Tahun .................................
3. ........................................ sebagai ..........................................................Tahun .................................

Riwayat Organisasi Ekstra

1. ........................................ sebagai ..........................................................Tahun .................................
2. ........................................ sebagai ..........................................................Tahun .................................
3. ........................................ sebagai ..........................................................Tahun .................................

Motto Hidup : ………………………………………………………………………………………………

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Cianjur,........................................2023

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Taqwa, Intelektual, Profesional