_—
eR. ‘A member of Musim Mos Group
_ es
MUSIM MAS aE
Form Aplikasi bagi Petani untuk Berpartisipasi pada
Program Pengembangan Petani Swadaya Kelapa Sawit Indonesia
Tanggal
IDENTITAS DIRI
Nama Lengkap Petani :
NIK q 4
Jenis Kelamin 7 2ESt/P
Nama Suami/istri : .
Alamat Rumah
Desa/Kelurahan :
Kecamatan e
Kabupaten :
No. Handphone 2
IDENTITAS KEBUN .
Saya menyatakan memil Meter/Rantai/Hektar Kebun Kelapa Sawit dengan data karakteristik
sebagai berikut :
lLegatitas Kebun ——
I. SH (Surat Hak Milk) ae
i. SKGR (Surat Keterangan _| Jenis Tanah pada Areal japply ke} Nar
vee Sl Tatum IGanti Rugi) Kebun | | pombe
No Kebun MTertanam aman} i. SKI/SK Camat Deaaeega tyes Teak)
(Ha) | (Ha) la. Lainctain Kelapa Sawit|
[skt/ sx] skaR/ | Lain- [Minera Lain.
sHiM
Camat| sGR | tain | /arat|°?"™™") tain
1
2
3 7
Untuk Staff Penyelenggara Program Tanggal ‘A member of Musim Mas Group
a som
MUSIM MAS
‘Alamat Kebun :
No. Dusun Desa -Kecamatan Kabupaten
SKETSA KEBUN
Saya menyatakan tertarik dan ingin berpartisipasi pada “Program Pengembangan Petani
Swadaya Kelapa Sawit Indonesia", Mohon dipertimbangkan aplikasi saya dan ingin memproleh informasi
lebih lanjut mengenal aktivitas yang dilakukan
Untuk Staff Penyelenggara Program MUSIM MAS,
INFORMASI LAHAN (
‘Amember of Musin Mas Group
\wwwmmusimmes.com
Tipe Kecambah / Bibit
Beli bibit/ kecambah dari
“el
Harga per kecambah / bibit
Bahan tanam yang digunakan : Bersertifikat Tidak bersertifikat
Seleksi / afkir sebelum tanam Ya » Ledtidak
Umur bibit saat tanam 5
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