No. : …………………….

FORMULIR PENDAFTARAN
TIM BASKET STIKES KHARISMA PUTRI
Tingkat Prodi : …………………….

Foto Berwarna
( 4x6 )

Nama Lengkap

:

TTL

:

NIM

:

No. Telepon / HP

:

Email

:

Tinggi Badan

:

Berat Badan

:

Kata-kata dukungan untuk tim :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

Jadwal dan Tempat Latihan :

Hari

Tempat

Jam

Tanda Tangan Pengisi

………………………….

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