formulir

LEMBAGA

PUSAT KEGIATAN BELAJAR MASYARAKAT

" BAHRUL ILMI  "

SAMARINDA KALIMANTAN TIMUR

NNSP: P2961485 IZIN OPR: 421.9/034/DP.IV.B/101-04/02/2018  Akta Notaris : No/49/17/12/2008

Alamat : KH. Harun Nafsi Samarinda  RT 15 Rapak Dalam Kec. Loa Janan Ilir  Hp. 085346913857/ 081346257159

FORMULIR & PERNYATAAN

No:.....................................

Yang bertanda tangan di bawah ini;

Nama                          :...................................................................................................................................................

Tepat, Tgl Lahir         :...................................................................................................................................................

Asal Sekolah              :...............................................................................................Tahun.......................................

No. Ijazah                   :...................................................................................................................................................

No. Danim/SKHU      :...................................................................................................................................................

No. Peserta Ujian       :...................................................................................................................................................

Nik / Ktp                    :...................................................................................................................................................

No KK                         :...................................................................................................................................................

Paket Yang diikuti     :...................................................................................................................................................

Alamat                        Jalan:.........................................................................................................................................

                                    Rt / Rw/ No...............................Kelurahan......................................................................

                                    Kecamatan.............................................................................................................................

                                    Kota / Kab..............................................................................................................................

                                    Provinsi...................................................................................................................................

                                    No Tlp........................................Hp..1................................................2.................................

Nama Ayah/Wali       :..........................................................................................Th Lahir........................................

Pekerjaan                   :..........................................................................................Penghasilan................................

Nama Ibu                   :...........................................................................................Th Lahir......................................

Pekerjaan                   :..........................................................................................Penghasilan................................

Alamat                        :...................................................................................................................................................

Telp/Hp                     :1..................................................................2...........................................................................

Dengan ini mohon diterimasebagai warga belajar di Lembaga PKBM Bahrul Ilmi Samarinda Kalimantan timur dan sesudah saya diterima menjadi warga belajar  maka saya bersedia mematuhi semua Peraturan dan tata tertib Pkbm tersebut . demikian surat Pernyataan dan Formulir dan digunakan sebagai mana Mestinya.