|
"BINA KARYA
COM" |
Alamat : Jln. Raya
Bajang - Mlarak Ponorogo / Utara Perempatan Jabung |
Telp. (0352)
312571. HP. 082143777483 – 0852 307 577 00 . E. Mail.
Syahrudin.mahakarya14@gmail.com |
|
|
|
|
FORMULIR
PENDAFTARAN TAHUN 2016 |
|
Nama |
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
Gelar Depan |
|
Gelar Belakang |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Pendidikan Terakhir |
: |
|
SD |
|
|
SLTP |
|
SLTA |
|
D 1 |
|
|
D 2 |
|
|
D 3 |
|
|
S 1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Jenis Kelamin |
: |
|
Laki - Laki |
|
|
Perempuan |
|
|
|
Tgl |
|
Bulan |
|
Tahun |
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Tempat/Tgl Lahir |
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
/ |
|
|
/ |
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Agama |
: |
|
Islam |
|
|
Kristen |
|
|
Katholik |
|
|
Hindu |
|
|
Budha |
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Alamat Rumah |
: |
Jalan |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Desa |
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Kecamatan |
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Kabupaten |
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Propinsi |
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Kode Pos |
: |
|
|
|
|
|
|
Tlp. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Hp. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Materi / Program Kursus |
: |
|
MICROSOFT WORD, |
|
|
|
MEMBUAT EMAIL |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
MICROSOFT EXCEL , |
|
|
|
MEMBUAT BLOG |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MICROSOFT POWER POINT. |
|
|
Web |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Hari Dan
Waktu Kursus |
: |
|
SELASA - JUM`AT |
13.00-15.00 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ibu |
: |
......................................... Pekerjaan : ........................ |
|
|
|
|
|
|
|
|
Ayah |
: |
......................................... Pekerjaan : ........................ |
|
|
|
|
|
|
|
|
Alamat: |
: |
……………………………………………………………………………………………………… |
|
Telp. Rumah |
: |
……………………………………………………………………………………………………… |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Dengan ini saya menyatakan bahwa informasi yang saya tuliskan
diatas adalah benar. Dan saya bersedia mengikuti kursus ini dengan
sebaik-baiknya. |
|
KETENTUAN ADMINISTRASI KEUANGAN DAN FASILITAS |
|
|
|
1 |
Biaya pendaftaran Rp.25.000 |
|
|
|
Fasilitas : |
1 |
BUKU PANDUAN/MODUL |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2 |
Buku dan alat tulis Dan
Stiker |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3 |
Layar LCD Proyektor |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
4 |
Pemateri |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5 |
Pembayaran Bisa Diangsur Selama Pendidikan
Berlangsung. |
|
|
|
6 |
Lama Pendidikan 9 kali
pertemuan |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
7 |
Biaya paket Kursus Rp 500.000 |
|
|
NB.
Untuk Wilayah Kota Bertempat di GMC Depan Kantor PLN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ponorogo, ……………………………………….. |
|
Diterima oleh |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(………………………………….) |
|
|
|
|
|
|
(………………………………….) |
|
|
Sekretaris |
|
|
|
|
|
|
Pendaftar |
|
|
Tidak ada komentar:
Posting Komentar