MAJELIS PENDIDIKAN DASAR DAN MENENGAH

SMA MUHAMMADIYAH 3 GRESIK

TERAKREDITASI A
Sekretariat : Jln. Raya Bungah KM. 17 Gresik 61152, Telp./Fax. 031-3948974
E-mail : info.smadiga.gresik@gmail.com

FORMULIR PENDAFTARAN SISWA BARU

TAHUN PELAJARAN 2010 / 2011
IDENTITAS SISWA

Nama Calon Siswa : ........................................................................................

Tempat/Tgl. Lahir : .................................. / ..................................................
NISN : ........................................................................................
Jenis Kelamin : Laki-laki/Perempuan *)
Agama : ........................................................................................
Kebangsaan/Suku : ........................................................................................
Golongan Darah : A/ B/ AB/ O **)
Tinggi/ Berat Badan : ............ Cm/..........Kg
Asal Sekolah : ........................................................................................
Nomor Ijazah : ........................................................................................
Jumlah DANUN : ........................................................................................
Jumlah Nilai Ujian Sekolah : ........................................................................................
Alamat Siswa/ No. Telp. : ........................................................................................
: ........................................................................................
ORANG TUA

1. Nama Ayah : ........................................................................................

Pekerjaan : ........................................................................................
Pendidikan : ........................................................................................
Alamat : ........................................................................................

2. Nama Ibu : ........................................................................................

Pekerjaan : ........................................................................................
Pendidikan : ........................................................................................
Alamat : ........................................................................................

WALI

1. Nama Wali : ........................................................................................

Pekerjaan : ........................................................................................
Pendidikan : ........................................................................................
Alamat : ........................................................................................
Hubungan Keluarga : ........................................................................................

Pembayaran Sekolah ditanggung oleh : 1. Ayah 2. Ibu 3. Wali 4. Lain-lain **)

Bungah, ............................ 2010

Orang Tua/Wali, Calon Siswa

_______________________ _______________________
(Nama Terang & Tanda Tangan (Nama Terang & Tanda Tangan)

*) Coret salah satu **) Pilih salah satu