KEMENTERIAN AGAMA

MADRASAH ALIYAH NEGERI RANCAH

IK H

LA S BERA M A L

KABUPATEN CIAMIS
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FORMULIR BIODATA SISWA MAN RANCAH

Mohon semua diisi dengan lengkap!
NOMOR IDENTITAS
Nomor Peserta Ujian MTs/SMP

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

NISN

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

Nomor STTB/Ijazah

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

Nomor SKHUN
IDENTITAS SISWA

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

Nama lengkap

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

Jenis Kelamin

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

Tempat, Tgl Lahir

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

Umur

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

Agama

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

Hobi

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

Cita-cita

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

Jarak Ke Sekolah

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

Alat Transportasi

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

Status

: Anak Kandung/Tiri/Lainnya)*

Keluarga

Jumlah Saudara

: Kandung ...................................... Tiri ......................................

Penerima BSM
: Ya/Bukan)*
IDENTITAS ORANG TUA/WALI
Nama Orang Tua

: Ayah ...................................... Ibu ......................................

Pendidikan

: Ayah ...................................... Ibu ......................................

Pekerjaan

: Ayah ...................................... Ibu ......................................

Penghasilan

: Ayah ...................................... Ibu ......................................

Agama

: Ayah ...................................... Ibu ......................................

Alamat

: Dusun.........................................RT/RW .......... ......No...............

Desa................................Kec. ............... ..........Kab. ...................

No. Telp/HP

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

No. Kartu Keluarga

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

IDENTITAS SEKOLAH ASAL

Nama Sekolah Asal
: ............................................................................................................................................
Status Sekolah

: Negeri/Swasta/Paket C/Pesantren)*

Alamat Sekolah
: ............................................................................................................................................
Tanggal/Bulan/Tahun

Lulus

: ............................................................................................................................................
Nilai Rata-rata Ujian

............................................................................................................................................
PRESTASI YANG DIMILIKI
Bidang Akademis
: ............................................................................................................................................
Bidang Olah Raga
: ............................................................................................................................................
Bidang Kesenian
: ............................................................................................................................................
Bidang Keagamaan
: ............................................................................................................................................

Bidang Lainnya
: ............................................................................................................................................
)* coret yang tidak perlu
Mengetahui :

......................................, ..............................2014

Orang Tua/ Wali Siswa

Siswa,

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