FORMULIR PENDAFTARAN KARTU TANDA ANGGOTA FORKOM PEKAMAS KAB SEMARANG TAHUN 2015

FORMULIR PENDAFTARAN KARTU TANDA ANGGOTA FORKOM PEKAMAS KAB SEMARANG

TAHUN 2015

 

                                                                                                                                                                Nomor Urut

      I.      Lokasi PKL/ Asongan                          :   ......................................................................................................................

     II.      Identifikasi Pedagang                        

Nama                                                       :   ......................................................................................................................

Tempat, Tanggal Lahir                        :   ......................................................................................................................

Agama                                                     :          Islam                          Kristen                                 Katholik               

                                                                  :          Hindu                          Budha                                   Lainya   

Pekerjaan                                               :          Suami                         Pegawai Pemerintah                         Dagang

                                                                                                                  Pegawai Swasta                                                Tani

                                                                                                                  Buruh                                                    Lainnya

                                                                                                         Penghasilan suami per bulan                  : Rp.    ...........................

           Istri                              Pegawai Pemerintah                         Dagang

                                                                                                                  Pegawai Swasta                                                Tani

                                                                                                                  Buruh                                                    Lainnya

                                                                                                         Penghasilan istri per bulan                       : Rp.    ...........................

Tanggungan Keluarga                        :   Jumlah              ............... Jiwa.                      Jenis Kelamin     L    .........   P    .........

Alamat Tempat Tinggal                       :   Dsn. / Lingk ...................................   RT  ..................  RW  ..................

                                                                      Desa   .....................................................................................................

                                                                      Kec  .................................................................  Kab/ Kota ....................................

    III.        Identifikasi Usaha                              :

Agama                                                   :          Bangunan Permanen                                             Gerobag tidak beroda                     

                                                                :          Bangunan semi permanen                                   Gerobag beroda

Ukuran Tempat Usaha                     :   .............   m  X    ............................m                =      ..................... m²            

Jenis Tempat Usaha                         :          Gelaran                      Tenda                   Lesehan                Selter

Tanda Daftar Usaha                          :          Ada                             Tidak Ada

SKPD yang memberi ijin                  :   .......................................................................................................................

Jenis Usaha/ Dagangan                   :          Kuliner                       .................................................................................              

:          Kerajinan                  Baju, Sepatu, Sandal dan Tas

                                                                :          Barang Antik            Tanaman Hias                    Burung / Ikan Hias

                                                                  :          Bengkel/ Tambal Ban, dll                                      Lainnya

Penghasilan Usaha                           :   Jumlah Omzet per hari                 Rp.          ................................

:   Jumlah Modal per hari                  Rp.          ................................

:   Pendapatan Bersih                       Rp.          ................................

Fasilitas Permodalan                        :          Bantuan Hibah dari Pemerintah                 APBN             APBD I                   APBD II

                                                                           BANK                 BPR               KOPERASI             Lainnya

Keterangan :

-   Beri tanda silang (x) pada kolom, sesuai kondisi/ data yang ada

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Ketua Paguyuban   .........................................                                   Pedagang Kaki Lima

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