Form PM. 7.5.

1/L1
Rev.0

FORMULIR
PENDAFTARAN CALON SISWA BARU
TAHUN PELAJARAN 2013/2014
A.

KETERANGAN PRIBADI
1. Nama
2. Nama Panggilan
3. Jenis Kelamin
4. Tempat/ Tanggal Lahir
5. Golongan darah
6. Agama
7. Alamat Asal
8. Alamat Sekarang
9. No. Telepon/HP
10. Jumlah saudara kandung/tiri
11. Bahasa sehari-hari
B. PENDIDIKAN
1. Sekolah Asal
2. Ijazah Terakhir
3. Tanggal/ No. STK
4. Alamat Sekolah
5. Lama Belajar
6. Nilai Rata-rata SKHUN
C. ORANG TUA
1. Nama Orang Tua

:
:
:
:
:
:
:
:
:
:
:

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

:
:
:
:
:
:

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

a. Ayah
: ....................................................................................
b. Ibu
: .................................................................................
.................................................................................................................................
a. Ayah
: Masih Hidup/ Sudah Meninggal
b. Ibu
: Masih Hidup/ Sudah Meninggal
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

2. Pekerjaan Orang Tua

3. Keadaan Orang Tua

:
:

4.
5.
6.
7.

:
:
:
:

Alamat Orang Tua

Nama Wali Siswa
Alamat Wali
No. Telepon/HP

D. SYARAT-SYARAT DAN YANG DILAMPIRKAN

1. Persyaratan Tetap :
No

Syarat-syarat

Banyak

Foto copy Ijazah yang dilegalisir

1 Lembar

2.

Foto copy STK/ NUN yang dilegalisir

1 Lembar

3.

Pas Photo ukuran 3x4 Cm hitam putih

2 Lembar

4.

Kartu Keterangan berbadan Sehat

1 Lembar

5.

Foto copy Raport Kelas 3 (tiga) semester I dan II yang dilegalisir

1 Lembar

Ada

Tidak Ada

2. Test Fisik
No.

Keadaan Fisik

Data Fisik

1.

Tato

Ya

2.

Tindik

Ya

3.

Tinggi Badan

... Cm.

4.

Berat Badan

... Kg.

Keterangan
Tidak
Tidak

Catatan
- Mengisi tabel/ Kolom ada/ tidak ada adalah panitia PSB
- Mengisi Data Pribadi harus sesuai dengan Ijazah / STK / SKHU SMP
- Calon siswa hanya mengisi data bagian atas, tanda tangan wali/ orang tua dan calon siswa

Sampit,.2013
Mengetahui,
Orang Tua/Wali

()

Calon Siswa,

(..)