Nama Lembaga :

………………………………………….......…..…...………………………………
Nama Pimpinan :
………………………………………………………………………………………..
Anggota :
.,......................................................................................................................

NIP :-
………………………………………….......…..…...………………………………

Golongan/Pangkat :
………………………………………….......…..…...………………………………

NPWP :
Tempat/TanggalLahir :
………………………………………….......…..…...………………………………
Jabatan :
………………………………………….......…..…...………………………………
Unit Kerja :
………………………………………….......…..…...………………………………
Alamat Kantor :
………………………………………….......…..…...………………………………
………………………………………….......…..…...……
…………..Telp.

Alamat Rumah :
………………………………………………………………………………………
Email :
………………………………………………………………………………………
Hp./WA :
…………………….,........................................................................................
Pendidikan :
……….,..........................................................................................................

Rekening :Bank
………………………………….……..........…..………………………

Cabang/Unit
………………………………….……..........…..…………

Nomor
………………………………….……..........…..…………

Atas Nama
………………………………….……..........…..…………

PROPOSAL :
……………………………………………………………..
Tahun :
…………………………………………………………….
Tempat :
..

Direktorat Jenderal Pendidikan IsIam,

Muhammad Ali Ramdhani