BIODATA CALON PESERTA DIDIK

1. Nomor Pendaftaran

: ......................... (Silahkan lihat di:

man2mataram.sch.id)
2. Nama Lengkap

:
...................................................................................

.............
3. Tempat dan Tangal Lahir

:
...................................................................................

.............
4. Nomor Induk Siswa Nasional (NISN)

...................................................................................
.............
5. Jenis Kelamin

:
...................................................................................

.............
6. Anak ke

:
...................................................................................

.............
7. Status dalam Keluarga

:
...................................................................................

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8. Alamat

:
...................................................................................

.............
a. Desa/Kelurahan

:
...................................................................................

.............
b. Kecamatan

:
...................................................................................

.............
c. Kabupaten/Kota

:
...................................................................................

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d. Provinsi

:
...................................................................................

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9. Nomor Telp/HP

:
...................................................................................

.............

10.E-mail

:
...................................................................................

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11.Sekolah/Madrasah

:
...................................................................................

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12.Nama Asal Sekolah/Madrasah

:
...................................................................................

.............
13.Alamat Sekolah/Madrasah

:
...................................................................................

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14.Orangtua
a. Nama Ayah

:
...................................................................................

.............
b. Nama Ibu

:
...................................................................................

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15.Alamat Orangtua

:
...................................................................................

.............
16.Nomor Telp/HP

:
...................................................................................

.............
17.Pekerjaan Orangtua
a. Ayah

: 1. TNI/Polri

2. PNS

3. PNS (Dosen/Guru)

4. Swasta 5. Wirausaha 6. Petani/Buruh

7.

Lainnya
b. Ibu

: 1. TNI/Polri

2. PNS

3. PNS (Dosen/Guru)

4. Swasta 5. Wirausaha 6. Petani/Buruh

7. Ibu rumah tangga

8. Lainnya

Mataram,

April 2015

Calon Peserta Didik

_____________________
Catatan :
Biodata ini bisa diserahkan langsung atau kirim melalui E-mail MAN 2 Model Mataram
(info@mail.man2mataram.sch.id)