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FORM PESERTA PROGRAM MAGANG/PRAKERIN/PKL
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Nama Lengkap
*
Your answer
Nama Panggilan
*
Your answer
No. WA
*
Your answer
Tempat Lahir
*
Cilacap
Banyumas
Purbalingga
Banjarnegara
Other:
Tanggal Lahir
*
MM
/
DD
/
YYYY
Jenis Kelamin
*
Laki-laki
Perempuan
Asal Kabupaten Rumah
*
Cilacap
Banyumas
Banjarnegara
Other:
Asal Kecamatan Rumah
*
Kroya
Binangun
Other:
Asal Desa Rumah
*
Kroya
Other:
Alamat Rumah (Jl, Nomor, RT, RW)
*
Your answer
Kontak Penanggungjawab (Nama orangtua)
*
Your answer
Nomor WA Kontak Penanggungjawab (Nama orangtua)
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Your answer
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