GERAKAN PRAMUKA

KWARTIR RANTING PETERONGAN

Alamat Sekretariat : Jl. Kol. H. Ismail No. 99 Tugusumberjo Peterongan
Telp. (0321) 861911, 085646123401
JOMBANG

BIODATA PESERTA
KURSUS PEMBINA MAHIR TINGKAT DASAR (KMD)
TANGGAL 1 s.d. 5 NOVEMBER 2017

UTUSAN : .................................................................................
NAMA : .................................................................................
TEMPAT TANGGAL LAHIR : .................................................................................
ALAMAT RUMAH : .................................................................................
ALAMAT KANTOR/GUDEP : .................................................................................
TELPON/WA : .................................................................................
EMAIL : .................................................................................
JABATAN DI PRAMUKA : .................................................................................
NOMOR KTA : .................................................................................
PENDIDIKAN
SD/MI : .................................................................................
SMP/MTS : .................................................................................
SMA/MA/SMK : .................................................................................
S1/DIV : .................................................................................
S2 : .................................................................................
MOTO : .................................................................................
MOTIVASI IKUT KMD : .................................................................................
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JENIS KURSUS/PELATIHAN YANG PERNAH DIIKUTI :

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4.
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Calon peserta KMD

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Keterangan:
1. dilampiri FC ijazah terakhir
2. diisi dengan benar sesuai ijazah
3. foto berseragam Pramuka 3x4 (4 lembar)