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    This document is a registration form for the Persaudaraan Setia Hati Terate organization in Madiun, Indonesia. It collects personal information about Adhimas Ian Baskoro including his name, date of birth, religion, occupation, education history, martial status, and family details. The form is used to document Adhimas Ian Baskoro's involvement with the organization.

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    1. ADHIMASBASKOR

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    This document is a registration form for the Persaudaraan Setia Hati Terate organization in Madiun, Indonesia. It collects personal information about Adhimas Ian Baskoro including his name, date of birth, religion, occupation, education history, martial status, and family details. The form is used to document Adhimas Ian Baskoro's involvement with the organization.

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    9 views3 pages

    Adhimasbaskor

    Uploaded by

    Jess No Titid
    This document is a registration form for the Persaudaraan Setia Hati Terate organization in Madiun, Indonesia. It collects personal information about Adhimas Ian Baskoro including his name, date of birth, religion, occupation, education history, martial status, and family details. The form is used to document Adhimas Ian Baskoro's involvement with the organization.

    Copyright:

    © All Rights Reserved
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    of 3

    PERSAUDARAAN SETIA

    PUSAT MADIUN - I
    KEMENKUMHAM RI : IDM 000142
    Sekretariat Pus
    Padepokan Agung PERSAUDARAA
    Jl. Merak No. 10 - Kota Madiun - Provins
    Telp. 0351-451548, 491046 Fax. 0351-473357

    FORMULIR BUKU INDUK WAR


    Nomor Urut :
    NIW
    Diisi oleh Pengurus Pusat

    1. DATA ORGANISASI :
    Nama Cabang : SRAGEN
    Nama Ranting : KALIJAMBE
    Nama Rayon : JETIS KARANGPUNG
    (tempat latihan) : LAPANGAN BANARAN
    ...................................................................................

    2. DATA PRIBADI
    Nama Lengkap : ADHIMAS IAN BASKORO
    Jenis Kelamin : LAKI-LAKI
    Tempat, Tgl, Lahir : SUKOHARJO,11 JANUARI 1997
    Kelahiran : SABTU LEGI
    Agama : ISLAM
    Pekerjaan : WIRASWASTA
    Alamat : KAUMAN RT02/01, KRAGAN,GONDANGREJO,KARANGANYAR
    ...................................................................................
    Kecakapan Khusus : ...................................................................................
    Berat Badan : 55 KG
    Tinggi Badan : 168 CM

    PERHATIAN :
    1. ISI DATA DENGAN BENAR
    AUDARAAN SETIA HATI TERATE
    USAT MADIUN - INDONESIA
    ENKUMHAM RI : IDM 000142231 dan IDM000142233
    Sekretariat Pusat :
    n Agung PERSAUDARAAN SETIA HATI TERATE
    10 - Kota Madiun - Provinsi Jawa Timur - Indonesia 63128
    491046 Fax. 0351-473357 email : pusatmadiunpsht@gmail.com

    UKU INDUK WARGA CABANG SRAGEN


    Pendidikan Umum :
    No. Nama Sekolah/Lembaga Pendidikan
    1 SD NEGERI 1 JERON
    2 SMP ISLAM BAKTI 1 SURAKARTA
    3 SMK MUHAMMADIYAH 1 GONDANGREJO
    4 S1
    Pendidikan Latihan Siswa di Persaudaraan Setia Hati Terate
    No. Tingkatan Tahun
    1 Polos 2021
    2 Jambon 2021
    3 Hijau 2022
    4 Putih 2022
    Jenjang Pendidikan Warga Persaudaraan Setia Hati Terate
    No. Tingkatan Tahun Pengesahan
    1 Tingkatan I
    2 Tingkatan II
    3 Tingkatan III
    3. DATA KELUARGA
    Nama Orang Tua/Wali :
    Pekerjaan :
    Alamat
    ......................................................
    Nama Isteri : AYU PUJI HASTUTI
    Pekerjaan : KARYAWAN SWASTA
    Pendidikan terakhir : SMK
    3x4
    Yang Membuat Pernyataan,

    ADHIMAS IAN BASKORO


    Ijasah Tahun
    2008
    2011
    2014

    Lama Latihan
    3 Bulan
    3 Bulan
    3 Bulan
    3 Bulan

    Tempat Pengesahan

    .......................................

    AN SWASTA

    uat Pernyataan,

    AN BASKORO

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