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FORMULIR PEMESANAN
FORMULIR PENDAFTARAN KEJUARAAN PENCAK SILAT IPSI CUP 3 KOTA MOJOKERTO
FORMULIR PENDAFTARAN MPMOJOKERTO KESATRIA WILWATIKTA CUP 1
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KASUAL DBEZ BJ02
SANDAL BUSTONG PRIA DBEZ SF01
SEPATU FORMAL DBEZ BN01
SEPATU KANTOR KULIT PRIA DBEZ L20
SEPATU KASUAL DBEZ BJ02
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FORMULIR PENDAFTARAN KEJUARAAN PENCAK SILAT IPSI CUP 3 KOTA MOJOKERTO
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Nama
*
Jenis Kelamin
*
Putra
putri
Tempat & Tanggal Lahir
*
Tinggi Badan
*
Berat Badan
*
Pendidikan
*
SD/MI/Sederajat
SMP/MTS/Sederajat
SMA/MA/Sederajat
Mahasiswa/Dewasa
Nama & Alamat Sekolah
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Nama Perguruan Silat & Alamat Rumah
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Nomor Handphone
*
Email
*
Kategori Pertandingan
*
Tanding Usia Dini SD1 (Kelas 1 & 2)
Tanding Usia Dini SD2 (Kelas 3 & 4)
Tanding Usia Dini SD3 (Kelas 5 &6)
Seni Tunggal SD/MI/Sederajat
Tanding Pra Remaja (SMP/MTS/Sederajat)
Seni Tunggal SMP/MTS/Sederajat
Tanding Remaja (SMA/MA/Sederajat)
Seni Tunggal SMA/MA/Sederajat
Dewasa (Usia 17-23 Tahun)
Seni Tunggal Dewasa
Seni Ganda Dewasa
Seni Beregu Dewasa
Tanding Usia Dini SD Kelas 1&2
A (0-18) Kg
B (18-20) Kg
C (20-22) Kg
D (22-24) Kg
E (24-26) Kg
F (26-28) Kg
G (28-30) Kg
H (30-32) Kg
I (32-34) Kg
J (34-36) Kg
K (36-38) Kg
L di atas 38 Kg
Tanding Usia Dini SD Kelas 3&4
A (0-20) Kg
B (20-22) Kg
C (22-24) Kg
D (24-26) Kg
E (26-28) Kg
F (28-30) Kg
G (30-32 Kg
H (32-34) Kg
I (34-36) Kg
J (36-38) Kg
K (38-40) Kg
L diatas 40 Kg
Tanding Usia Dini SD Kelas 5&6
A (0-22) Kg
B (22-24) Kg
C (24-26) Kg
D (26-28) Kg
E (28-30) Kg
F (30-32) Kg
G (32-34) Kg
H (34-36) Kg
I (36-38) Kg
J (38-40) Kg
K (40-42) Kg
L diatas 42 Kg
Tanding Pra Remaja (SMP/MTS/Sederajat)
A (30-33) Kg
B (33-36) Kg
C (36-39) Kg
D (39-42) Kg
E (42-45) Kg
F (45-48) Kg
G (48-51) Kg
H (51-54) Kg
I (54-57) Kg
J (57-60) Kg
K (60-63) Kg
L di atas 63 Kg
Tanding Remaja (SMA/MA/Sederajat)
A (39-43) Kg
B (43-47) Kg
C (47-51) Kg
D (51-55) Kg
E (55-59) Kg
F (59-63) Kg
G (63-67) Kg
H (67-71) Kg
I (71-75) Kg
J (75-79) Kg
K (79-83) Kg
L di atas 83 Kg
Kategori Seni Tunggal
SD/MI/Sederajat Tangan Kosong
SD/MI/Sederajat Bersenjata
SMP/MTS/Sederajat Tangan Kosong
SMP/MTS/Sederajat Bersenjata
SMA/MA/Sederajat Jurus Lengkap
Tanding Dewasa
A (45-50) Kg
B (50-55) Kg
C (55-60) Kg
D (60-65) Kg
E (65-70) Kg
F (70-75) Kg
G (75-80) Kg
H (80-85) Kg
I (85-90) Kg
J diatas 90 Kg
Kategori Seni Dewasa
Tunggal
Ganda
Regu
Pas Foto
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Bukti Pembayaran
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