Formulir Pendaftaran Anggota PMR [PDF]

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FORMULIR PENDAFTARAN ANGGOTA PMR

Nama Lengkap

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

Tempat/Tanggal Lahir

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

Jenis Kelamin

:L/P

Golongan darah

: O / A / B / AB

Agama

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

Alamat Lengkap

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

Photo 3X4

.................................................................... No. Telepon Rumah

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

Sekolah

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

HP

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

E-mail

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

Sekolah/Madrasah

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

Motivasi Menjadi PMR

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

Mengetahui Orang Tua / Wali

Yang bersangkutan

(.........................................)

(.........................................) Kepala Sekolah/Pimpinan Lembaga/ Pembina PMR

(.........................................)