YAYASAN AL-HALIMAH IRHAMNA BIL-QUR’AN

Akta Notaris INDRI SRIMENGANTI, SH., M.Kn. NO. 2 Tgl. 07/06/2014

PONDOK PESANTREN TAHFIDZ

IRHAMNA BIL-QUR’AN
Alamat: Jl. Raya Pantai Carita KM. 17, Desa Pari RT/04 RW/01, Kec. Mandalawangi, Kab. Pandeglang Prov. Banten 42261
NSP: 512036010160 Email: irhamnabilquran@gmail.com Web: http://www.irhamnabilquran.or.id

FORMULIR BEASISWA PENGEMBANGAN DIRI TAHUN PELAJARAN 2022-2023

A. Data diri santri

Nama lengkap : .............................................................................................................................
Tempat, Tanggal Lahir : .............................................................................................................................
Pendidikan Terakhir : .............................................................................................................................

B. Data Orang Tua / Wali

Nama Ayah : .............................................................................................................................
Tempat, Tanggal Lahir : .............................................................................................................................
Pendidikan Terakhir : .............................................................................................................................
Profesi / Pekerjaan : .............................................................................................................................
Penghasilan rata-rata / Bulan : .............................................................................................................................

Nama Ibu : .............................................................................................................................

Tempat, Tanggal Lahir : .............................................................................................................................
Pendidikan Terakhir : .............................................................................................................................
Profesi / Pekerjaan : .............................................................................................................................
Penghasilan rata-rata / Bulan : .............................................................................................................................

C. Alamaat Orang Tua

Jl / Kp : .............................................................................................................................
RT / RW : .............................................................................................................................
Desa / Kelurahan : .............................................................................................................................
Kecamatan : .............................................................................................................................
Kota / Kabupaten : .............................................................................................................................
Provinsi : .............................................................................................................................

Paket Beasiswa Pengembangan Bahasa Asing:

1. Bebas biaya Kursus Bahasa Inggris 1 Bulan di kampung Inggris Pare – Jawa Timur
2. Bebas biaya Kursus Bahasa Arab 1 Bulan di kampung Inggris Pare – Jawa Timur

D. Lampiran *Wajib
1. Surat Pernyataan
2. Ijazah terakhir asli
3. 1 Lembar FC Kartu Keluarga
4. Akte Kelahiran asli

Mengetahui Mandalawangi, ............/ .........../ 2022

Bag. Kepesantrenan Santri calon penerima Beasiswa

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