Form Pendaftaran 2019
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MARCHING BAND ISTIQLAL KANTOR SEKRETARIAT: RUANG 63B MASJID ISTIQLAL Jl. Taman Wijayakusuma, Pasar Baru - DKI Jakarta, 10710 | Telp. 0821-1203-8041 E-mail : [email protected]
FORMULIR ANGGOTA BARU MARCHING BAND ISTIQLAL TAHUN 2019 Yang bertandatangan di bawah ini, menyatakan kesediaannya untuk menjadi anggota Marching Band Istiqlal Jakarta tahun 2019 - 2020: A. Data Pribadi Nama Lengkap
: ................................................................................................
Nama Panggilan
: ................................................................................................
Tempat/ Tanggal Lahir
: ................................................................................................
Jenis Kelamin
: ................................................................................................
Umur
: ................................................................................................
Alamat
: ................................................................................................ ................................................................................................. .................................................................................................
Nomor yang dapat dihubungi dalam keadaan darurat
: ............................................
B. Data Orang Tua/ Wali Nama Orang Tua/ Wali
: ................................................................................................
Pekerjaan
: ................................................................................................
Alamat
: ................................................................................................ ................................................................................................. .................................................................................................
……………, ……………………… 2019 Peserta Foto 3x4
(………………………..…………)
FORMULIR ANGGOTA BARU MARCHING BAND ISTIQLAL TAHUN 2019 Yang bertandatangan di bawah ini, menyatakan kesediaannya untuk menjadi anggota Marching Band Istiqlal Jakarta tahun 2019 - 2020: A. Data Pribadi Nama Lengkap
: ................................................................................................
Nama Panggilan
: ................................................................................................
Tempat/ Tanggal Lahir
: ................................................................................................
Jenis Kelamin
: ................................................................................................
Umur
: ................................................................................................
Alamat
: ................................................................................................ ................................................................................................. .................................................................................................
Nomor yang dapat dihubungi dalam keadaan darurat
: ............................................
B. Data Orang Tua/ Wali Nama Orang Tua/ Wali
: ................................................................................................
Pekerjaan
: ................................................................................................
Alamat
: ................................................................................................ ................................................................................................. .................................................................................................
……………, ……………………… 2019 Peserta Foto 3x4
(………………………..…………)
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