formulir Pendaftaran Mahasantri

KEMENTERIAN AGAMA
INSTITUT AGAMA ISLAM NEGERI JEMBER

MA’HAD AL-JAMI’AH
Sekretariat : Jl. Mataram No.01 Mangli 68139 Telp. 081233676420

No :
......................
Di isi panitia
......................
: ...................................................................................................................
....

FORMULIR PENDAFTARAN

(Isilah dengan benar dan lengkap, coret yang idak perlu)

1. Nama Lengkap
2. Jenis Kelamin
Tempat, Tgl Lahir

: Laki-laki / Perempuan
: ..................................................................................................................

3. Kewarganegaraan

: WNA / WNI

4. Alamat Rumah

: ...................................................................................................................

Kabupaten/Kota

: ...................................................................................................................

Propinsi

: ...................................................................................................................

No Telp/Hp

: ...................................................................................................................

Email

: ...................................................................................................................

5. Nama Ayah

: .........................................................................Umur:...............................

Nama Ibu

: .........................................................................Umur:...............................

Alamat

: ...................................................................................................................

No Telp/Hp Ayah

: ...................................................................................................................

Pekerjaan

: ...................................................................................................................

No Telp/Hp Ibu

: ...................................................................................................................

Pekerjaan

: ...................................................................................................................

6. Asal Sekolah

: ..................................................................................................................

Jurusan

: ...................................................................................................................

7. Asal Ma’had

: ...................................................................................................................

8. Fakultas/Prodi

: ................................... / ............................................................................

9. Prestasi

: 1. ............................................................................, Tingkat : .................
2. ............................................................................, Tingkat : .................

10. Hafal al-Qur’an

: Ya / Tidak

Jumlah Hafalan

: .......... Juz

11. Alasan Mendaftar

11. Hafal Hadist
Jumlah Hafalan

: Ya / Tidak
: .......... Hadis

: ...................................................................................................................
...................................................................................................................
...................................................................................................................
Jember, ....................... 2017

Calon Santri

Orang Tua/Wali

FOTO
3X4

(.............................................)

(.............................................)