ISNTITUT PRIMA BHAKTI (IPB) PAMEKASAN

Approved by: Department of Education No. : 421.9/2715/441.302/2003

Department of Manpower No. : 563/106/441.314/2003

Kantor pusat: Jl. Dirgahayu 22 Pamekasan - Madura - Jawa Timur 081703934340

FORMULIR PENDAFTARAN

Nama : ................................................................................................

Alamat : ...............................................................................................

Tempat/Tgl. Lahir : ...............................................................................

Asal sekolah/PT : .................................................................................

Jenis kelaman : .....................................................................................

Mengetahui Institut Prima Bhakti dari  teman, iklan atau lainnya  (lingkari salah satu yang bercetak miring)

sanggup mentaati peraturan di Institut Prima Bhakti baik lisan maupun tulisan.

Membayar :

uang pendaftaran : Rp. 15.000,-

uang buku Rp. 15.000,-

Uang pendidikan : Rp. ................................

Jumlah : ......................................................

  tanda tangan penerima                                                            tanda tangan siswa

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