‫معهد دار القرآن عائشة رضي الله عنها للبنات‬PONDOK PESANTREN DARUL QURAN PUTRI ‘AISYAH RADHIYALLAHU ‘ANHALEMBAGA SOSIAL DAN DAKWAH ISLAM (LSDI) “SALMAN AL-FARISI RADHIYALLAHU „ANHU”
Notaris: Anis Khusnul Farida, SH. No. 02 Tgl 15 Maret 2010. Reg. Pengadilan No. 76/2010/PN/Kab. Kediri. NPWP : 31.172.875.2-655.000
Sekretariat : Jl. RA Kartini 19 RT 02 RW 01 Dsn Gayam Barat Ds. Gayam Kecamatan Gurah Kabupaten Kediri 64181 Jawa Timur‫بسم هللا الرحمن الرحيم‬FORMULIR PENDAFTARAN SANTRI BARUTAHUNH/MNomor Pendaftaran: ..............

DATA SANTRI:
1. Nama Asli: ...........................................................................................................
2. Nama Alias/Kuniyah : ...........................................................................................................
3. Tempat, Tanggal lahir : ...........................................................................................................
4. Usia saat mendaftar : .................. tahun .................... bulan
5. Anak ke: .................. dari .................. saudara (.............. putri ............ putra)
6. Pendidikan terakhir : Formal : ............................................................................................
Selesai/tidak selesai tahun: ..............................................................
Non Formal: ......................................................................................
Selesai/tidak selesai tahun: ..............................................................
7. Hafalan Al-Quran: ............ juz ............. surat
Rincian ............. juz dari belakang ............. dari depan.
DATA ORANG TUA:
1. Nama Ayah
: ...................................................................... usia ................. tahun.
2. Agama Ayah
: .............................................. Pekerjaan: ..........................................
3. Nama Ibu: ...................................................................... usia ................. tahun.
4. Agama Ibu: .............................................. Pekerjaan: ..........................................
5. Alamat Ortu Lengkap : (sesuai KTP).
Jln. ............................................................... No. ................ Gg/Blok .......................
RT. ............... RW. .............. Dkh/Dsn. .......................................................................
Ds/Kel. ........................................................ Kec. ......................................................
Kab/Kot. ..................................................... Prop. ....................................................
Kode Pos ....................................................
No. Telepon Rumah: .................................. No. Hp: .................................................
6. Alamat tempat tinggal ortu saat ini:
Jln. ............................................................... No. ................ Gg/Blok .......................
RT. ............... RW. .............. Dkh/Dsn. .......................................................................
Ds/Kel. ........................................................ Kec. ......................................................
Kab/Kot. ..................................................... Prop. ....................................................
Kode Pos ....................................................
No. Telepon Rumah: .................................. No. Hp: .................................................
NAMA-NAMA MAHRAM:
1. ..................................................... Status Mahram: ...............................................................
2. ..................................................... Status Mahram: ...............................................................
3. ..................................................... Status Mahram: ...............................................................
4. ..................................................... Status Mahram: ...............................................................
5. ..................................................... Status Mahram: ...............................................................

ISIAN BAGI SANTRI YANG DITANGGUNG
OLEH SELAIN ORANG TUA
Nomor Pendaftaran: ..............

DATA SANTRI:
1. Nama Asli: ...........................................................................................................

2. Nama Alias/Kuniyah : ...........................................................................................................
3. Tempat, Tanggal lahir : ...........................................................................................................
DATA WALI/PENANGGUNG BIAYA:
1. Nama Lengkap: ...................................................................... usia ................. tahun.
2. Pekerjaan: ..........................................................................................................

3. Alamat Lengkap:Jln. ............................................................... No. ................ Gg/Blok .......................
RT. ............... RW. .............. Dkh/Dsn. .......................................................................
Ds/Kel. ........................................................ Kec. ......................................................
Kab/Kot. ..................................................... Prop. ....................................................
Kode Pos ....................................................
No. Telepon Rumah: .................................. No. Hp: .................................................
JIKA DITANGGUNG OLEH LEMBAGA:
1. Nama Lembaga: ...........................................................................................................
2. Alamat Lengkap:Jln. ............................................................... No. ................ Gg/Blok .......................
RT. ............... RW. .............. Dkh/Dsn. .......................................................................
Ds/Kel. ........................................................ Kec. ......................................................
Kab/Kot. ..................................................... Prop. ....................................................
Kode Pos ....................................................
No. Telepon Kantor: .................................. No. Hp: .................................................
3. Nama Pimpinan: ..........................................................................................................

4. No. Telepon Pimpinan: Rumah: .................................. No. Hp: .............................................
5. Status Santri di Lembaga: ......................................................................................................
ALASAN PENANGGUNGAN SANTRI:
1. Orang tua ada namun kurang mampu (2. Tugas Belajar()

3. Asalnya Yatim/Yatimah ())

4. Lainnya ..........................................

......................................., ....................................... H........................................ M
Ortu/Wali/Pengantar

Calon Santri

Panitia(.................................................)(............................................)(...................................)