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2. Blangko Daftar Ulang

2. Blangko Daftar Ulang

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Dipublikasikan oleh Miens Surat

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Published by: Miens Surat on Jan 27, 2012
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Lampiran 1

SURAT PERNYATAAN PESERTA DIDIK
SMK NEGERI 4 MALANG
Saya yang bertanda tangan di bawah ini :
1 Na!a "eng#a$ :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
& Te!$at' tangga" "ahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
( )eni* #e"a!in :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+ N,!,r $enda-taran :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Diteri!a di #e"a*/01r1*an : %%%%%/
%%%%%%%%%%%%%%%%%%%%%%
2 Na!a ,rang t1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
3 Pe#er0aan ,rang t1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Aga!a ,rang t1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
15 A"a!at ,rang t1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
11 Na!a wa"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1& Pe#er0aan wa"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1(61b1ngan #e"1arga dengan wa"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
14 A"a!at wa"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1+N,!,r te"e$,n/6$ ,rang t1a/wa"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Dengan *1ngg1h 7 *1ngg1h dan $en1h #e*adaran :
MENYATAKAN
8ahwa *e"a!a !en0adi *i*wa' *aya
%%%%%%%%%%%%%%%%%%%%%%%%%%%
1 A#an be"a0ar dengan te#1n dan $en1h *e!angat
& A#an !en0aga na!a bai# diri *endiri' #e"1arga dan *e#,"ah
( Sangg1$ !entaati dan !e!at1hi #egiatan be"a0ar !enga0ar *etia$ hari'
$e"a#*anaan 9iyata!anda"a dan tata tertib *e#,"ah
4 A#an !engi#1ti $endidi#an aga!a
%%%%%%%%%%%%%%%%%%%%%%%
+ A#an !engi#1ti #egiatan E#*tra K1ri#1"er yang di"a#*ana#an ,"eh *e#,"ah
. A$abi"a tida# !entaati #etent1an yang diteta$#an ,"eh *e#,"ah' *aya *angg1$
!eneri!a *ang*i' yait1 :
a Tida# di$er#enan#an !engi#1ti $e"a0aran *e"a! 0ang#a wa#t1 tertent1
b Di#e!ba"i#an #e ,rang t1a / wa"i !1rid
Pernyataan ini *aya b1at dengan *ebenar 7 benarnya dan dengan $en1h tangg1ng
0awab *erta di#etah1i/di*et101i ,rang t1a / wa"i:; *aya
Ma"ang' %%%%%%%%%&5%%
Mengetah1i/ Menyet101i Yang !e!b1at
Pernyataan
<rang T1a / 9a"i
Materai
R$ .555'=
%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%
>ATATAN :
1 :; ?,ret yang tida# $er"1
Lampiran 2
SURAT PERNYATAAN <RANG TUA / 9ALI
>AL<N PESERTA DIDIK SMK NEGERI 4 MALANG
Saya yang bertanda tangan di bawah ini :
1 Na!a <rang T1a / 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
& Pe#er0aan <rang T1a / 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
( A"a!at <rang T1a / 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
+ Na!a $e*erta didi# :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
. )eni* #e"a!in :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
2 Diteri!a di #e"a* / )1r1*an :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
3 61b1ngan #e"1arga dengan ?a",n $e*erta didi# :
%%%%%%%%%%%%%%%%%%%%%%%%%%%
MENYATAKAN
8ahwa *e"a#1 ,rang t1a / wa"i :; dari $e*erta didi# berna!a :
%%%%%%%%%%%%%%%%%%%%%%%%% #e"a*
%%%%%%%Pr,gra! Keah"ian %%%%%%%%%%%%%%%%%
SMK Negeri 4 Ma"ang' Saya :
1 8er*edia !e!bi!bing dan !engawa*i ?a",n $e*erta didi# ter*eb1t di ata* 1nt1#
!entaati dan !e!at1hi $e"a#*anaan 9iyata!anda"a' ter!a*1# $a#aian
*eraga! *e#,"ah' tata tertib *e#,"ah dan #egiatan be"a0ar !enga0ar *etia$ hari
& Pe*erta didi# ter*eb1t di ata* a#an !engi#1ti $endidi#an aga!a
%%%%%%%%%%%%%%
( Tida# #eberatan *i*wa ter*eb1t diata* !eneri!a *ang*i antara "ain :
a Tida# di$er#enan#an !engi#1ti $e"a0aran *e"a!a 0ang#a wa#t1 tertent1
b Di#e!ba"i#an #e$ada *aya
A$abi"a *aya tida# !e!bi!bing dan !engawa*i *ehingga $e*erta didi# ter*eb1t tida#
!entaati #etent1an yang diteta$#an
Pernyataan ini *aya b1at dengan *ebenar 7 benarnya dan dengan $en1h tangg1ng
0awab
Ma"ang' %%%%%%%%%&5%
Yang !e!b1at $ernyataan
<rang T1a / 9a"i
%%%%%%%%%%%%%%%%
>ATATAN :
1 :; >,ret yang tida# $er"1
PEMERINTAH KOTA MALANG
DINAS PENDIDIKAN
SMK NEGERI 4 MALANG
)" Tani!bar && Ma"ang .+211 Te"$ @ 5(41; (+(243 'AaB @5(41; (+(243
E-mail : surat@smkn4-mlg.info
LEM8AR 8UKU INDUK SIS9A
A KETERANGAN TENTANG DIRI SIS9A
1 Na!a "eng#a$ :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
& Na!a $anggi"an :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
( )eni* #e"a!in :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Te!$at C Tg" Lahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+ Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Kewarganegaraan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2 Ana# #e bera$a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
3 )1!"ah *a1dara :
a Kand1ng :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Tiri :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
? Ang#at :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
d Ana# #e :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Ana# Yati!/Piat1/Yati! Piat1 :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
15 8aha*a *ehari 7 hari :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
8 KETERANGAN TEMPAT TINGGAL
11 A"a!at r1!ah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%
1&N, te"e$,n / 6P :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1( E=!ai" :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
14 Tingga" dengan : <rang t1a/Sa1dara/#,*t/
%%%%%%%%%%%%%%%%%%%
1+ )ara# te!$at tingga" dari *e#,"ah : %%%%%%%%%%%%#!
> KETERANGAN KESE6ATAN
1. G,",ngan darah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
12 Penya#it yang $ernah diderita :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
13 Ke"ainan 0a*!ani :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
14 Tinggi badan %%%%%%%?! dan berat badan %%%%%% #g
D KETERANGAN PENDIDIKAN
&5 Pendidi#an *ebe"1!nya
a A*a" SMP/MT* :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Tah1n "1"1* %%%%%%%%% dan N, I0aDah
%%%%%%%%%%%%%%%%%%%%%%%
? La!a be"a0ar di SMP / MT* :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&1 Pindahan
a Dari *e#,"ah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b A"a*an $indah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&& Diteri!a di *e#,"ah ini :
a Ting#at :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b 8idang Keah"ian :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
? Pr,gra! Keah"ian :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
d Tangga" :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
E KETERANGAN TENTANG AYA6 KANDUNG
&( Na!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&4 Te!$at C Tangga" Lahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&+ Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&. Kewarganegaraan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&2 Pendidi#an Tera#hir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&3 Pe#er0aan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&4 Penda$atan $er b1"an : R$
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(5 A"a!at r1!ah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
(1 Ma*ih hid1$/Meningga" D1nia Tah1n :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A KETERANGAN TENTANG I8U KANDUNG
(& Na!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(( Te!$at C Tangga" Lahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(4 Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(+ Kewarganegaraan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(. Pendidi#an Tera#hir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(2 Pe#er0aan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(3 Penda$atan $er b1"an : R$
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
(4 A"a!at r1!ah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
45 Ma*ih hid1$/Meningga" D1nia Tah1n :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
G KETERANGAN TENTANG 9ALI
41 Na!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4& Te!$at C Tangga" Lahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4( Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
44 Kewarganegaraan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4+ Pendidi#an Tera#hir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4. Pe#er0aan :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
42 Penda$atan $er b1"an : R$
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
43 A"a!at r1!ah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
44 Ma*ih hid1$/Meningga" D1nia Tah1n :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
6 KEGEMARAN DAN KE<RGANISASIAN >AL<N SIS9A
+5 Ke*enian :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+1 <"ah raga :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%
+& Ke!a*yara#atan / <rgani*a*i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+( Lain 7 "ain :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Ma"ang'
%%%%%%%%&5%
<rang T1a / 9a"i M1rid Si*wa
%%%%%%%%%%%
%%%%%%%%%%%%%%%%
PEMERINTAH KOTA MALANG
DINAS PENDIDIKAN
SMK NEGERI 4 MALANG
)" Tani!bar && Ma"ang .+211 Te"$ @ 5(41; (+(243 'AaB @5(41; (+(243
E-mail : surat@smkn4-mlg.info
8IM8INGAN DAN K<NSELING
A<T<
( E 4
DATA PRI8ADI SIS9A
1 Na!a *i*wa @"eng#a$; :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
& N, Ind1# :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
( )eni* Ke"a!in :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Te!$at/Tangga" Lahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+ Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. A"a!at Si*wa :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N,Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
2 Se#,"ah A*a" :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
3 I0aDah/S1rat Tanda Ke"1"1*an/S1rat Tanda L1"1*
a Tah1n :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b N,!,r :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Diteri!a di *e#,"ah ini
a Di ting#at :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Pada tangga" :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
15 Na!a <rang T1a
a Ayah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Ib1 :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
11 A"a!at <rang T1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
1& Pe#er0aan
a Ayah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Ib1 :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1( Pengha*i"an <rang T1a
a Ayah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Ib1 :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
14 Na!a 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1+ A"a!at 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
1. Pe#er0aan 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
12 61b1ngan *i*wa dengan wa"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
13 Kegiatan di "1ar *e#,"ah
a %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
b %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
? %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
14 )ara# r1!ah dari *e#,"ah : %%%%%#!
&5 8erang#at / P1"ang *e#,"ah : ber0a"an #a#i / nai# *e$eda / *e$eda
!,t,r / antar 0e!$1t /
Kendaraan 1!1!
&1 )1!"ah 1ang *a#1 *ehari 7 hari : R$
%%%%%%%%%%%%%%%%%%%%%%%%%%%%
8I<DATA 8UKU RAP<RT
KETERANGAN TENTANG PESERTA DIDIK
1 Na!a $e*erta didi# @"eng#a$; :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
& N,!,r Ind1# :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
( )eni* Ke"a!in :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Te!$at dan Tangga" Lahir :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+ Aga!a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. A"a!at Pe*erta Didi# :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N,Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
2 A*a" Se#,"ah
a Na!a Se#,"ah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b A"a!at :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%
3 S1rat Tanda Ta!at 8e"a0ar/I0aDah/S1rat Tanda Ke"1"1*an/S1rat Tanda L1"1*
a Tah1n :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b N,!,r :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
4 Diteri!a di *e#,"ah ini
a Ke"a* :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Pada Tangga" :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
15 Na!a <rang T1a
a Ayah :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b Ib1 :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
11 A"a!at <rang T1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
1& Pe#er0aan <rang T1a :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1( Na!a 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
14 A"a!at 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N, Te"$/6P
%%%%%%%%%%%%%%%%%%%%%%%%
1+ Pe#er0aan 9a"i :
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Ma"ang'
%%%%%%%%&5%
<rang T1a / 9a"i M1rid Si*wa
%%%%%%%%%%%
%%%%%%%%%%%%%%%%

20…… Yang membuat Materai Rp.. *) coret yang tidak perlu Lampiran 2 SURAT PERNYATAAN ORANG TUA / WALI CALON PESERTA DIDIK SMK NEGERI 4 MALANG Saya yang bertanda tangan di bawah ini : 1. Agama : ……………………………………………………………………… 5. kelas …………………. Nama Orang Tua / Wali : ……………………………………………………………………… 2. Nama peserta didik : ……………………………………………………………………… 6. SMK Negeri 4 Malang. Hubungan keluarga dengan calon peserta didik : ……………………………………………………………………… MENYATAKAN Bahwa selaku orang tua / wali *) dari peserta didik bernama : ………………………………………………………………….. Diterima di kelas / Jurusan : ……………………………………………………………………… 8. Jenis kelamin : ……………………………………………………………………… 7.000. ………………………. Pekerjaan Orang Tua / Wali : ……………………………………………………………………… 3.Program Keahlian ……………………………………………. 6. termasuk pakaian seragam sekolah.Mengetahui/ Menyetujui Pernyataan Orang Tua / Wali Malang.………………………………………. Saya : 1. Bersedia membimbing dan mengawasi calon peserta didik tersebut di atas untuk mentaati dan mematuhi pelaksanaan Wiyatamandala. tata tertib sekolah dan kegiatan belajar mengajar setiap hari. …………………………………………… CATATAN : 1. Alamat Orang Tua / Wali : ……………………………………………………………………… 4. .

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