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YAYASAN PENDIDIKAN KESEJAHTERAAN ISLAM AL-IKHLAS SOE USAHA KESEHATAN SEKOLAH (UKS) MADRASAH TSANAWIAH AL-IKHLA SOE Jl. Ikan Paus No. 16 Oekefan Tlp. (0388)22896



Nama NIS/NISN Ttgl Jenis Kelamin Agama Alamat No.HP



: .............................................. : .............................................. : .............................................. : .............................................. : .............................................. : .............................................. ................................................ ................................................ : .............................................. SoE, 01 November 2018 Kepala Madrasah



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Dra. Hj. Musyawarah, MM NIP. 19670921 199703 2 002