Formulir pendaftaran Arhesa Swimming Club

    

  ARHESA SWIMMING CLUB

FORMULIR PENDAFTARAN

 DATA PRIBADI

N a m a                                                :_______________________________________________________

N a m a  Panggilan                              : _________________________________________________________

Tempat/Tgl. Lahir                     :_______________________________________________________

Jenis kelamin                                        :  Laki-laki / Perempuan   ^*)

Agama                                                   :_______________________________________________________

Hobi                                                       :  ________________________________________________________

Nama Ayah                                           :  ________________________________________________________ 

Nama Ibu                                              :  ________________________________________________________

Alamat rumah                                       :_______________________________________________________ ­

                                  ______________________________________________________

                           Kelurahan        :_______________________________________________________

                           Kecamatan       :  __________________________ RT  :  _______   RW :_________

    Kota / Kab.           :  ___________________________  Kode Pos    :  ________________

Tlp:______________________ HP   :  __________________________

                                E-mail                    : _________________________________________________

                               

___________

^*)   Coret yang tidak sesuai