formulir-pendaftaran-maltiq
TRANSCRIPT
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
3 x 4