FORMULIR CALON MAHASANTRI BARU

PROGRAM MA’HAD ALY

I. DATA DIRI CALON SANTRI BARU

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

2. Jenis Kelamin : Laki-laki Perempuan

3. Tempat/Tgl. Lahir : ........................., ...................................................................

4. Pendidikan Terakhir : .............................................................................................

5. No. Telp/HP/WA : .............................................................................................

6. Email/Fb : .............................................................................................

7. Alamat Lengkap : .............................................................................................

: .............................................................................................

8. Hobi dan Bakat : .............................................................................................

II. DATA ORANG TUA CALON SANTRI BARU

A. A Y A H

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

2. Pekerjaan : .............................................................................................

3. Keadaan Ayah Masih ada Meninggal

4. No. Telp/HP/WA : ..............................................................................................

5. Email/Fb : ..............................................................................................

6. Alamat Lengkap : ..............................................................................................

: .............................................................................................

B. I B U

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

2. Pekerjaan : .............................................................................................

3. Keadaan Ibu Meninggal

4. No Telp/HP/WA : .............................................................................................

5. Email/Fb : ..............................................................................................

6. Alamat Lengkap : ..............................................................................................

: .............................................................................................

C. WALI (Diisi, jika yang mendaftarkan selain orang tua)

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

2. Pekerjaan : .............................................................................................

3. No Telp/HP/WA : .............................................................................................

4. Alamat Lengkap : ..............................................................................................

: .............................................................................................

5. Keadaan Wali ..........................................................

MA’HAD TAHFIZHUL QUR’AN AL FIRQOH AN NAJIYAH No. Statistik Pondok Pesantren Depag RI: 51.0.33.50.70.615

Alamat: (Utara PUSDIK ARHANUD) Masjid Baitul Makmur - Desa Donowarih - Kec. Karangploso - Kab. Malang – Jawa Timur. Telp (0341) 465-134, website: www.firqotunnajiyah.com

III. KETERANGAN KESEHATAN CALON SANTRI BARU

1. Penglihatan Baik Cukup Kurang

2. Pendengaran Baik Cukup Kurang

3. Golongan Darah A B O AB

4. Penyakit yang pernah diderita : ……………………………………………………….

IV. PRESTASI

1. ……………………………………………………………………………………….

2. ……………………………………………………………………………………….

3. ………………………………………………………………………………………..

V. PENGALAMAN ORGANISASI

1. ..........................................................................................................................

2. . .........................................................................................................................

3. ..........................................................................................................................

VI. LATAR BELAKANG PENDAFTARAN

1. Kehendak siapa ......................................................................................................

2. Alasan .....................................................................................................................

3. Target yang diinginkan ...........................................................................................

VII. HAL-HAL YANG DISEPAKATI BERSAMA

1. Siap melaksanakan semua peraturan y

2. Mengganti semua biaya pendidikan jika tidak menyelesaikan studi sesuai waktu

Tidak

3. Santri wajib mengikuti program pengabdian selama 1 tahun

……………, ………/…………………/2015

Tanda Tangan

Calon Santri Baru

.................................………….. Nama Jelas

Tanda Tangan Orang tua / wali

.................................………….. Nama Jelas

Pas Photo

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