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    11 views2 pages

    Form Pendaftaran Invitasi 2022

    Uploaded by

    Naufal Alaudin

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    KORPS SUKARELA PALANG MERAH INDONESIA

    UNIT UNIVERSITAS MUHAMMADIYAH PURWOREJO


    Sekretariat : Ruang Student Health Center (SHC), Gedung UKM Kampus Timur
    Jln. K. H. Ahmad Dahlan No.6 Purworejo. Hp: 0895382754464
    Email: ksrpmiunitumpurworejo@gmail.com

    FORMULIR PENDAFTARAN LOMBA INVITASI PALANG MERAH REMAJA (PMR)


    WIRA SE- EKS KERESIDENAN KEDU TAHUN 2022
    Asal Sekolah : ……………………………………… No Telp/WA : …………………………
    Alamat : …………………………………………………………………………….
    A. Pembina PMR

    Nama : …………………………………………………………….
    photo NIP/NTA : …………………………………………………………….
    3x4
    berwarna TTL : ……………………………………………………………..
    Alamat : ……………………………………………………………..
    No Telp/WA: ……………………………………………………...........

    B. Peserta

    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    1. 3x4
    berwarna TTL : ………………………………………………………
    Alamat : ………………………………………………………
    No Telp/WA : ………………………………………………………

    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    2. 3x4
    berwarna TTL : ………………………………………………………
    Alamat : ………………………………………………………
    No Telp/WA : ………………………………………………………

    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    3. 3x4
    berwarna TTL : ………………………………………………………
    Alamat : ………………………………………………………
    No Telp/WA : ………………………………………………………

    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    4. 3x4
    TTL : ………………………………………………………
    berwarna
    Alamat : ………………………………………………………
    No Telp/WA : ………………………………………………………
    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    3x4
    5. TTL : ………………………………………………………
    berwarna
    Alamat : ………………………………………………………
    No Telp/WA : …………………………………………………

    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    3x4
    6. TTL : ………………………………………………………
    berwarna
    Alamat : ………………………………………………………
    No Telp/WA : …………………………………………………

    Nama : ………………………………………………………
    photo NTA/NIS : ………………………………………………………
    3x4
    7. TTL : ………………………………………………………
    berwarna
    Alamat : ………………………………………………………
    No Telp/WA : …………………………………………………

    NB : Formulir Pendaftaran dikirimkan melalui link https://bit.ly/DaftarInvitasi22

    ……………………, … …………… 2022


    Pembina PMR

    ……………………………………

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