FORMULIR PENDAFTARAN SANTRI BARU

Transkripsi

1 No. Pendaftaran: FORM A MA'HAD AL-ITTIHAD AL-ISLAMI FORMULIR PENDAFTARAN ISLAMI TERPERCAYA KOMPETITIF NAMA ALAMAT : : :

2 SURAT PERMOHONAN MENJADI SANTRI Kepada Yth. Bapak Pimpinan Ma had Al-Ittihad Al-Islami Camplong di-tempat Dengan hormat, yang bertanda tangan di bawah ini, saya: Nama Lengkap : Tempat / Tanggal Lahir : Alamat : : dengan segala kerendahan hati dan penuh harapan memohon kepada Bapak untuk diterima menjadi santri Ma had Al-Ittihad Al-Islami Camplong Tahun Pelajaran Dan sesuai dengan ketentuan-ketentuan yang berlaku, maka dengan sepenuh hati saya berjanji untuk: a. Mematuhi ketentuan pembayaran yang telah ditetapkan oleh Ma had, baik pada waktu pendaftaran ataupun setiap bulannya. b. Memenuhi dan menjalankan JANJI SANTRI sebagai berkut: 1. Percaya dan taat sepenuhnya kepada peraturan Ma had dan sanggup melaksanakan semua bimbingan dengan sebaik baiknya. 2. Sanggup berpegang teguh kepada prinsip prinsip pendidikan di Ma had Al-Ittihad Al-Islami Camplong dan bersedia mengikuti semua disiplin/tata tertib yang berlaku di dalam Ma had. 3. Bersedia menerima segala macam tindakan yang diberikan oleh atau atas nama Pimpinan Ma had untuk kebaikan bersama. Demikian surat permohonan ini saya sampaikan, kiranya dapat diterima. Amin. Ikut memohon, Orangtua / Wali Camplong, Calon Santri, (...) (...)

3 DATA IDENTITAS PRIMER yuhnamahpesertahdidikhblengkap0h8 OUhNomorhIndukA RUhTempatcTanggalhLahir wuhjenishkelamin,uhstatushdalamhkeluarga DATA PRIBADI 6Uhhhha0UhDiterimahdihMadrasahhinihdihkelasA 8hVIIhchVIIIhchIXhchXhchXIhchXIIhchTakhassushAAhhhhhhhhhhhhhhh hhhhhhhhb0uhpadahtanggala y3uhha0uhnamahsekolahcmadrasahhasal hhhhhhhhb0uhalamathsekolahcmadrasahhasal yyuhha0uhijazahhsdcmicsmpcmtsaahtahun youhha0uhskhuhsdcmicsmpcmtshaahtahun hhhhhhhhc0uhnomorhpesertahujianhnasional yguhha0uhnamahayahh hhhhhhhhb0uhnamahibu yruhha0uhalamathorangtua hhhhhhhhb0uhtelponchphorangtua ywuhha0uhpekerjaanhayah hhhhhhhhb0uhpekerjaanhibu No. Pendaftaran: FORM B * Diisi panitia ** Coret yang tidak perlu *** Kosongi bila tidak ada 8h_hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhGUhNISNhhhhhhhh8 8h hhhzhhhh_ 8hLakiHlakihchPerempuanhAAhhhh_UhAgamahhhhh8hh I S L A M 8hAnakhKandunghchAnakhTirihchAnakhAngkathAAhhhh-UhAnakhkehhhhhhhhh8hh_h 8h_hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhc0UhSemesterhAh8hIhbsatu0hchIIhbdua0hAA 8h hhhhhhb0uhnomorhijazahhhhhhhhhh8hh 8h hhhhhhb0uhnomorhskhuhhhhhhhhh 8hh DATA IDENTITAS SEKUNDER yuhnamahpanggilan OUhJumlahhSaudarahKandungcTiriAAA GUhJumlahhSaudarahAngkatAAA 8h hhhruhstatushanakaaahhhhhhhhhh8hyatimcpiatucyatimhpiatuaa 8h_hhhhhhhhhhhhhhhhhhchhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhwUhKewarganegaraanhhh8hWNIhchWNAAA 8h_hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh _UhBahasahSehariHharih8h DATA TEMPAT TINGGAL yuhalamathlengkap OUhTeleponcHP GUhTinggalhdengancdi RUhJarakhTempathTinggal 8hOrangtuahchSaudarahchAsramahchKosthAA DATA KESEHATAN yuhgolonganhdarah GUhRiwayathPenyakit RUhKelainanhJasmani 8hAhchBhchABhchOhAAhhhhhhhhhhhhOUhTinggicBerathBadan8hhhhhhhhhhhhhhhhhhhhhhhhhhhhcmhhchhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhkg 8hTBChchCacarhchMalariahchLainnyahbUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU0hAA DATA PENDIDIKAN yuhriwayathpendidikan hhhauh hscdhkelashh hbberijazahhchtidakaa0 hhhbuh hscdhkelashh hbberijazahhchtidakaa0 hhhcuh hscdhkelashh hbberijazahhchtidakaa0 OUhPindahanh hhhhauhdarihsekolah hhhhbuhalasanhkepindahan

4 DATA ORANGTUA/WALI F9yNamayAyahyKandungjjj '9yTempatHTanggalyLahir s9yagama -9yPendidikan :9yPekerjaan U9yPendapatanyperbulan 49yAlamatytinggal D9yTeleponHHP F9yNamayIbuyKandungjjj '9yTempatHTanggalyLahir s9yagama -9yPendidikan :9yPekerjaan U9yPendapatanyperbulan 49yAlamatytinggal D9yTeleponHHP F9yNamayWaliykPenanggungybiayajjj '9yTempatHTanggalyLahir s9yagama -9yPendidikan :9yPekerjaan U9yPendapatanyperbulan 49yAlamatytinggal D9yTeleponHHP DATA PRIBADI No. Pendaftaran: FORM B * Diisi panitia ** Coret yang tidak perlu *** Kosongi bila tidak ada :y ykmasihyhidupyhymeninggalydunia6jj :y yyybyyy_ :y yyybyyyw9ykewarganegaraany:ywniyhywnajj :ysdyhysmpyhysmayhydiplomayhysfyhys'yhyssyhylainnyayk jj :y ykmasihyhidupyhymeninggalydunia6jj :y yyybyyy_ :y yyybyyyw9ykewarganegaraany:ywniyhywnajj :ysdyhysmpyhysmayhydiplomayhysfyhys'yhyssyhylainnyayk jj :y yyybyyy_ :y yyybyyyw9ykewarganegaraany:ywniyhywnajj :ysdyhysmpyhysmayhydiplomayhysfyhys'yhyssyhylainnyayk jj KONTAK PENTING/DARURAT KaumyKerabatyHyKeluargayHyFamiliyyangyTerdekatydenganyMaPhadydanysewaktu8waktuybisaydihubungi: F9yNama '9yUmur s9ypekerjaan w9yalamatylengkap -9yTeleponyHyHP :y ytahun Demikianydataypribadiyiniysayayisiydenganysebenar8benarnya9 Mengetahuib OrangtuaHWalib Camplongby y'IFs CalonySantrib ky 6 ky 6

5 BLANGKO TES MINAT DAN KONSEP PRIBADI No. Pendaftaran: FORM-C78- -,I89 PETUNJUK UMUM : Isilah pertanyaan dan pernyataan di bawah ini dengan HURUF BALOK بسم االله الرحمن الرحيم KELOMPOK SOAL A 87-Data-Calon-Santri NamayLengkap NamayPanggilan Tempat)TanggalyLahir AlamatyAsal BahasaySehari1hari :y yyym Berilah tanda cawang (V) pada kotak jawaban yang sesuai dengan hati nurani anda sendiri,7-bisakah-anda-membaca-al6qurpan? yyyyyyybisayyyyyyyyyyyyyyyyybisaytetapiytidakylancaryyyyyyyyyyyyyyyyyyyyyyyyyyyyytidakybisaysamaysekaliyyyyyyyyyyyyyyyylancarydanymengertiytajwidnya 97-Bisakah-Anda-menulis-huruf-Arab? yyyyyyybisayyyyyyyyyyyyyyyyybisaytetapiybelumysempurnayyyyyyyyyyyyyyyyytidakybisaysamaysekaliyyyyyyyyyyyyyyyyytidakytertarik w7-apa-tujuan-anda-ingin-masuk-ke-lembaga-pendidikan-pondok-pesantren? (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( T7-Apakah-ada-yang-memaksa-Anda-masuk-ke-Pondok-Pesantren-ini? yyyyyyytidakydipaksa)kemauanysendiriyyyyyyyyyyyyyyyyyyamydipaksayorangtuayyyyyyyyyyyyyyyyydipaksaykakakyyyyyyyyyyyyyyyyydipaksaysaudara yyyyyyydisarankanyolehyustadz)guruyyyyyyyyyyyyyyyyyyyyyytidakytahuyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyapaykatayorangtuayyyyyyyylain1lain 67-Atas-biaya-siapa-Anda-belajar-di-Pesantren-ini? yyyyyyyorangtuaysendiriyyyyyyyyyyyyyyyyykakakyyyyyyyyyyyyyyyyyyfamiliyyyyyyyyyyyyyyyyyayasanyyyyyyyyyyyyyyylainnya 77-Dari-siapa/mana-Anda-tahu-Pesantren-Al6Ittihad-Al6Islami-Camplong-ini? yyyyyyykoran)majalahyyyyyyyyyyyyyyyyyyyyybrosuryyyyyyyyyyyyyyyyyorangtuayyyyyyyyyyustadzyyyyyyyyyyyyyyyyytemanyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyylainnya 87-Selain-mendaftarkan-diri-di-Pesantren-iniy-apakah-Anda-juga-mendaftarkan-di-ke-sekolah-lain? yyyyyyysmpyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyysmayyyyyyyyyyyyyyyyyyyyyyperguruanytinggiyyyyyyyyyyyyyyyyyyyyyyyyypesantrenylain 97-Setelah-lulus-SD/Sederajaty-apakah-Anda-pernah-menjadi-siswa-SMP/SMA/Perguruan-Tinggi? yyyyyyypernahyyyyyyyyyyyyyyyyyyyyyyyyyyytidakypernah 8I7-Bila-pernah-menjadi-siswa-SMP/SMA/Perguruan-Tinggi/Pesantren-lainy-mengapa-anda-harus-berhenti? yyyyyyytidakyadaybiayayyyyyyyyydikeluarkanyyyyyyyyyyyyyyyyytidakykerasanykarenayterlaluyketatytataytertibnyayyyyyyyyyyyyyyyyyyyyyyyyyalasanylain 887-Berapa-jumlah-saudara-anda-yang-masih-menjadi-tanggungan-orangtua? yyyyyyytidakyadayyyyyyyyyyyyyyyyyyyyyy3yzsatugyorangyyyyyyyyyyyy2yzduagyorangyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy3yztigagyorang)lebih 8,7-Apa-bidang-studi-yang-paling-anda-sukai? yyyyyyya(yolahragayzjenisgyyyyyyyyyyyy:y3gy(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((myyyyyyy2gy((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( yyyyyyyb(yketrampilanyzjenisgyyyyy:y3gy(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((myyyyyyy2gy((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( yyyyyyyc(ykesenianyzjenisgyyyyyyyyyyyy:y3gy(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((myyyyyyy2gy((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( yyyyyyyd(ylainnyayzsebutkangyyyyy:y3gy(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((myyyyyyy2gy(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((

6 BLANGKO TES MINAT DAN KONSEP PRIBADI No. Pendaftaran: FORMeCc8e e8-i9 I9ceApaebidangestudieyangepalingetidakeAndaesukai? 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7 BLANGKO TES MINAT DAN KONSEP PRIBADI No. Pendaftaran: FORM C KELOMPOK SOAL B BubuhkanjhurufjSj(Sering),jJj(Jarang),jHTPj(Hampirjtidakjpernah)jdanjPj(pernah)jpadajkotakjyangjtersedia! Contoh:jjjjjjjjjjjjjjjO,BjMerokok htp O,BjMerokok G,BjSukajminumjminumanjkeras U,BjMempunyaijpenyakitjmenular z,bjsukajmengganggujorangjlain Y,BjMerasajsulitjuntukjmeninggalkanjhobby jjjjjjjyangjkurangjsehat E,BjSukajmenontonjfilmIbioskopImainjgame R,BjSukajmengambiljuangjkeluargajtanpajijin J,BjMempunyaijdoronganjuntukjberdustaI jjjjjjberbuatjtidakjjujur N,BjTidakjsadarjmengambiljbarangjorangjlain O-,BjMerasajseringjmenyakitijorangjlain OG,BjMerasajdimanjajolehjorangtuaj OU,BjMerasajdiabaikanjolehjorangtuaj Oz,BjKeluargajhidupjberantakanjcperceraianwj jjjjjjjjjmeninggaljduniawjpermaduanwjcekcok,j OY,BjMerasajmalasjuntukjsekolahjSMPISMAj OE,BjMerasajmalasjbelajarjdijPesantrenj OR,BjPilihankujbelajarjtakjsesuaijdengan jjjjjjjjjpilihanjorangtuaj OJ,BjMerasajmulaijmencintaijseseorang ON,BjMerasajmulaijdicintaijseseorang G-,BjMerasajkhawatirjterhadapjakibatjdarij GO,BjInginjmenirujgayajiklanIfilmjdijTVIBioskop GG,BjKurangjbahagiajkarenajcacatjjasmaniIrohani GU,BjMerasajterpengaruhjsekalijolehjadeganjseks jjjjjjjjjdalamjbukuvbukujtvibioskop Gz,BjBeranijkejOrangtua GY,BjBeranijkejGuruIUstadz GE,BjSeringjmerasajtakutItertekanjdenganj jjjjjjjjjperaturanjorangtua GR,BjSulitjuntukjbelajarjteratur GJ,BjMerasajsangatjperluIpentingjdenganjilmujagama GN,BjSukajmeremehkanjorangjberbicara U-,BjSeringjpergijtanpajpamitjkepadajorangtua UO,BjMinderItidakjpercayajdirijjikajberbicara jjjjjjjjjdijdepanjumum UG,BjBanggajdenganjkeberadaanjAyah UU,BjBanggajdenganjkeberadaanjIbu Uz,BjSukajhidupjsehatIbersih UY,BjSukajbersolekIberdandan UE,BjAdajkeinginanjmencobaVcobajmodej jjjjjjjjjpakaianibarangjbaru UR,BjSukajbelanjajbarangjyangjtakjdiperlukanjcboros,j UJ,BjPernahjtawuran UN,BjPernahjjadijjuarajcsebutkanjdijbarisjbawah:, jjjjjjjjjadeganiacarajpercintaanjdijtvibioskop Daftarjjuara: O,jBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBwjjjjjjjG,jBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB U,jBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBwjjjjjjjz,jBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 21. Tulislah ulang pernyataan berikut ini dengan tanganmu sendiri! jjjjjjjo,jsayajberjanjijtidakjakanjmerokok jjjjjjjg,jsayajberjanjijdisiplinjibadahjdanjbelajar

8 BLANGKO TES MINAT DAN KONSEP PRIBADI No. Pendaftaran: FORM3C Tulislah3ulang3pernyataan3berikut3ini3dengan3tanganmu3sendiri!3(Lanjutan...) PPPPPPP3ZPSAYAPBERJANJIPAKANPPATUHPDANPTAATPTERHADAPPBIMBINGANPWPPEMBINAANPYANGPDIBERIKANPOLEHP PPPPPPPPPPPPPENGURUSPPESANTRENPDANPASATIDZ PPPPPPP4ZPSAYAPAKANPMENERIMAPHUKUMANPDENGANPIKHLASWPAPABILAPSAYAPMELANGGARPTATAPTERTIBPPESANTREN PPPPPPP5ZPSESUNGGUHNYAPIBADAHKUWPHIDUPKUPDANPMATIKUPHANYALAHPMILIKPALLAHPSWTPSEMATA CamplongWP...P2013 CalonPSantriW LP Z