BUKU RAPOT MADIN PP.APIK halaman 3

KETERANGAN DAN IDENTITAS SANTRI

Nama Lengkap                                  : .................................................................

Nomor Induk Santri                         : .................................................................

Jenis kelamin                                     : .................................................................

Tempat dan Tanggal Lahir             : .................................................................

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

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

Agama                                                : .................................................................

Di Terima Di Pondok ini                  : .................................................................

1. Hari                                        : .................................................................
2. Tanggal                                  : .................................................................

Nama Orang Tua                              : .................................................................

1. Ayah                                       : .................................................................
2. Ibu                                          : .................................................................

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

Nama Orang Tua Wali                     : .................................................................

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

Pas Photo 3x4

Kesugihan, ...................................

Pengasuh Pondok Pesantren APIK

Kesugihan-Cilacap

Ky. Muhdzir Saifulloh

Pengasuh