ONLINE REGISTRATION FORM

PANITIA PENERIMAAN SISWA BARU PERGURUAN DARUL HIKAM WAL IHSAN

DARUL HIKAM INTERNATIONAL SCHOOL

Jl.Ir.H.Juanda 285 Bandung - Jl. Maribaya No.89 Lembang

DIISI OLEH PENDAFTAR STUDENT PARTICULAR Full Name Gender Place, Date of Birth Nationality Email Address : : : : : : Male Female / d

Spoken Language Previous School Attended

: : No School Year

SIBLINGS INFORMATION Child Number No of siblings Siblings Name Date of Birth

PARENT INFORMATION Father Father's Name :

Nationality Place & Date of Birth Highest Education Email Address

: : : : :

Office Address Occupation Income Nature of Business Telephone Number Mobile Phone Number Mother Mother's Name Nationality Place & Date of Birth Highest Education Email Address

: : : : : : > 5 Million 5 - 10 Million 10 - 15 Million

: : : : : :

Office Address Occupation Income Nature of Business Telephone Number Mobile Phone Number

: : : : : : > 5 Million 5 - 10 Million 10 - 15 Million

MEDICAL HSTORY Does your child have any allergies ? Y N Describe

Medicine Immunization Food Asthma Epilepsy Others

GOT INFORMATION ABOUT DARUL HIKAM FROM Newspaper Pikiran Rakyat Republika Others, describe Radio, describe Internet TV, describe Family Coworkers Others, describe

Registration Requirement 1. FC. Birth Certificate 2. Color Photos 2x3 (2 pieces) Additional for Secondary 3. FC. Raport 5 Semester 4. FC. Diploma 5. FC. Daftar Nilau UAN (DAUAN) 6. Description from the Head of School for prospective students who have academic achievement HOW TO RETURN FORM email to: psb@darulhikam.com FAX to number 022 2505375

This Registration will be processed if it has been making payments to accounts BANK MUAMALAT KANTOR KAS DH 110 0000 104 A.N. MARI MARHAMAH & DIAN SUGIANTI Please fax proof of payment to the phone number 022 2505375 or by email psb@darulhikam.com

Declaration : 1. All the information given in this application form is true and correct 2. I understand and agree to by all the Regulation and Conditions of the School

Year Register for school PRIMARY New Student Registration Number Registration Date

Gel

SECONDARY Transfer

Date of Birth

School

/ d m

/ y

> 15 Million

/ d m

/ y

> 15 Million

Fathers Name Nationalit y Place and Date Of Birth Highest Education

E-mail Address Office Address Address Occupatio n Income Nature Of Business > 5 jt 5 -10 Jt 10-15Jt

Telephon e Number

Hand Phone Number

DD / MM / YY

10-15Jt

< 15 Jt