PESANTREN MAHASISWA AL-HUDA

Jl. H. Komarudin Gang Nusantara 9 No. 2 Rajabasa Raya

Kab. Bandar Lampung Provinsi Lampung 35144
website: www.pesmaalhuda.org Contact Person: +62 853-5772-1443

Formulir Pendaftaran Santri Baru

Tahun Ajaran : 2019/2020

A. Informasi Data Diri Calon Santri

1. Nama : ................................................................................................
2. Nama Panggilan : ................................................................................................
3. Kota/ Kab Tempat Kelahiran : ................................................................................................
Tanggal/Bulan/Tahun Kelahiran : ................................................................................................
Alamat Lengkap : ................................................................................................
4. Nomor Telepon/HP : ................................................................................................
5. Tinggi Badan : ............................................ Cm
6. Berat Badan : ............................................ Kg
7. Sakit Yang Pernah Diderita : ................................................................................................

B. Pendidikan

Riwayat Pendidikan
1. ...................................................................................................... Tahun ...............................
2. ...................................................................................................... Tahun ...............................
3. ...................................................................................................... Tahun ...............................
4. ...................................................................................................... Tahun ...............................

Jika Sudah Menjadi Mahasiswa

Asal Universitas : .......................................................................................................................
Alamat Universitas : .......................................................................................................................
Aktif Di Organisasi : .......................................................................................................................
Amanah Di Organisasi : .......................................................................................................................

C. Identitas Orang Tua/Wali Santri

1. Ayah Kandung/Tiri/Angkat/Santri
Nama : .......................................................................................................................
Tempat Tanggal Lahir: .......................................................................................................................
Agama : .......................................................................................................................
Pekerjaan / Instansi : .......................................................................................................................
Nomor Telepon/ HP : .......................................................................................................................

2. Ibu Kandung /Tiri/Angkat/Wali

3. Nama : .......................................................................................................................
4. Tempat Tanggal Lahir: .......................................................................................................................
5. Agama : .......................................................................................................................
6. Pekerjaan / Instansi : .......................................................................................................................
 PESANTREN MAHASISWA AL-HUDA
Jl. H. Komarudin Gang Nusantara 9 No. 2 Rajabasa Raya
Kab. Bandar Lampung Provinsi Lampung 35144
website: www.pesmaalhuda.org Contact Person: +62 853-5772-1443

7. Nomor Telepon/ HP : .......................................................................................................................

D. Minat Dan Kebiasaan

Hobi ( Boleh Lebih Dari Satu ) :

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

Prestasi Yang Pernah Diraih

1. .................................................................................................. Tahun ...........................................
2. .................................................................................................. Tahun ...........................................
3. .................................................................................................. Tahun ...........................................
4. .................................................................................................. Tahun ...........................................

Buku Keislaman, Baik Fiksi Maupun Non Fiksi Yang Paling Disukai :
1. ..........................................................................................................................................................
2. ..........................................................................................................................................................
3. ..........................................................................................................................................................

E. Motivasi/Alasan Masuk Pesantren

1. Motivasi Dan Alasan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
2. Dukungan Orang Tua
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
3. Mengetahui Kabar Pesantren Mahasiswa Dari :
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

Dengan Ini Saya Menyatakan Mendaftarkan Diri Menjadi Calon Santri Pesantren Mahasiswa Al Huda.

.................................... , ..................... 2019

PAS FOTO Yang Bertanda Tangan,
TERBARU
UKURAN
3x4
PESANTREN MAHASISWA AL-HUDA
Jl. H. Komarudin Gang Nusantara 9 No. 2 Rajabasa Raya
Kab. Bandar Lampung Provinsi Lampung 35144
website: www.pesmaalhuda.org Contact Person: +62 853-5772-1443

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