MADRASAH DINIYAH TAKMILIYAH AWALIAH

(MDTA)KHOIRU UMMAH
Alamat,Jl.Rokan Jaya Gg.Khoiru Ummah,Kel.Labuh Baru Barat,Kec.Payung Sekaki,Pekanbaru.RIAU
Nomor Statistik Madrasah: 311214710272

FORMULIR PENDAFTARAN SANTRI BARU

Nama Calon Santri : ........................................................................................................

NIK : ........................................................................................................

Tempat/Tgl Lahir : ........................................................................................................

Sekolah : ........................................................................................................

Kelas : ........................................................................................................

Nama Ayah/Wali* : ........................................................................................................

NIK : ........................................................................................................

Tempat/Tgl Lahir : ........................................................................................................

Pekerjaan : ........................................................................................................

Alamat : ........................................................................................................

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

Nomor Telfon : ........................................................................................................

Nama Ibu : ........................................................................................................

NIK : ........................................................................................................

Tempat/Tgl Lahir : ........................................................................................................

Pekerjaan : ........................................................................................................

Alamat : ........................................................................................................

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

Nomor Telfon : ........................................................................................................

................., .......... .........................

Pendaftar

.................................................
Lampirkan :
(KK) Kartu Keluarga
Foto 3X4 boleh hitam putih atau warna background bebas