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