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RUMAH YATIM

SAIDAH ANWAR

Komplek Pondok Cipta Mas II Jalan Pondok Cipta Mas Raya No. A-16

 Desa Laksana Mekar, Kec. Padalarang, Kab. Bandung Barat

 

 Tel (022) 86863099



 

 FORMULIR PENDAFTARAN

 CALON ANAK ASUH

 RUMAH YATIM SAIDAH ANWAR

 

 

 

1.       Nama Lengkap                                          : _____________________________________________________

 

2.       Nama Panggilan                                         : _____________________________________________________

 

3.       Tempat Tanggal Lahir                                : _____________________________________________________

 

4.       Jenis Kelamin                                            : _____________________________________________________

 

5.       Jumlah Keluarga Kandung                           : _________________anak ke : ___________________________

 

6.       Status                                                     : Yatim Piatu / Yatim / Piatu )*

 

7.       Alamat Keluarga                                        : _____________________________________________________

 

           _____________________________________________________

 

8.       Asal Sekolah                                             : _____________________________________________________

 

9.       Kelas                                                       : _____________________________________________________

 

10.   Riwayat Penyakit                                       : _____________________________________________________

 

(isi jika ada)

 

11.   Keterangan orang Tua / Wali

 

-          Nama Ayah                                                    : _____________________________________________________

 

-          Alamat

Lengkap                                              : _____________________________________________________

 

           ____________________________________________________

 

-          Nama Ibu                                                       : ____________________________________________________

 

-          Alamat Lengkap                                              : ____________________________________________________

 

           ____________________________________________________

 

-          Nama Wali                                                      : ____________________________________________________

 

-          Alamat Lengkap                                                : ____________________________________________________

 

             ____________________________________________________

 

                                                                                                           

 

                                                                                                                                                                                       

 

                                                 Foto 2 X 3                                                                                                     Padalarang, ……….,2015

 

 

 

 

                                  (_______________________________)                                                                                                         Calon Santri

 

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