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    FORMULIR USC 2022 2

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    Formulir Usc 2022 2

    Uploaded by

    Frevy Aulia

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    © All Rights Reserved
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    KEMENTRIAN AGAMA RI

    UIN SUNAN AMPEL SURABAYA


    UNIT KEGIATAN OLAHRAGA
    Jl. Jend Ahmad Yani 117 Surabaya kode Pos 60237 Surabaya Phone: 0858-1527-1311 e-mail: ukoruinsurabaya@gmail.com

    FORMULIR PENDAFTARAN
    UKOR SPORT CUP 2022

    Nama Sekolah : ……………………………………………………………………………………………………..

    Alamat Sekolah : ……………………………………………………………………………………………………..

    Nomer Telp. Sekolah : ……………………………………………………………………………………………………..

    Cabang Olahraga : ……………………………………………………………………………………………………..

    PEMAIN:
    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………


    KEMENTRIAN AGAMA RI
    UIN SUNAN AMPEL SURABAYA
    UNIT KEGIATAN OLAHRAGA
    Jl. Jend Ahmad Yani 117 Surabaya kode Pos 60237 Surabaya Phone: 0858-1527-1311 e-mail: ukoruinsurabaya@gmail.com

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………


    KEMENTRIAN AGAMA RI
    UIN SUNAN AMPEL SURABAYA
    UNIT KEGIATAN OLAHRAGA
    Jl. Jend Ahmad Yani 117 Surabaya kode Pos 60237 Surabaya Phone: 0858-1527-1311 e-mail: ukoruinsurabaya@gmail.com

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………


    KEMENTRIAN AGAMA RI
    UIN SUNAN AMPEL SURABAYA
    UNIT KEGIATAN OLAHRAGA
    Jl. Jend Ahmad Yani 117 Surabaya kode Pos 60237 Surabaya Phone: 0858-1527-1311 e-mail: ukoruinsurabaya@gmail.com

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    POSISI : ……………………………………………………………………………………………

    NO. PUNGGUNG : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    OFFICIAL:
    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    JENIS KELAMIN : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    JABATAN : ……………………………………………………………………………………………

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    JENIS KELAMIN : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    JABATAN : ……………………………………………………………………………………………
    KEMENTRIAN AGAMA RI
    UIN SUNAN AMPEL SURABAYA
    UNIT KEGIATAN OLAHRAGA
    Jl. Jend Ahmad Yani 117 Surabaya kode Pos 60237 Surabaya Phone: 0858-1527-1311 e-mail: ukoruinsurabaya@gmail.com

    Foto 3x4 NAMA : ……………………………………………………………………………………………

    TTL : ……………………………………………………………………………………………

    JENIS KELAMIN : ……………………………………………………………………………………………

    NO. TELP : ……………………………………………………………………………………………

    JABATAN : ……………………………………………………………………………………………

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