BIODATA SANTRI/SISWA
NO INDUK_ _ _ _
I. IDENTITAS PRIBADI
1. Nama Lengkap
: .
2. Tempat/Tgl Lahir
: .....................................................................................
3. Jenis Kelamin
4. Kebangsaan/suku
: .....................................................................................
5. Ijazah Terakhir
: .....................................................................................
6. Asal Sekolah
: .....................................................................................
Laki-Laki
Perempuan*
Foto
3X4
: .....................................................................................
Pekerjaan
: .....................................................................................
No. Telepon/HP
: .....................................................................................
2. Nama Ibu
No. Telepon/HP
: .....................................................................................
: .....................................................................................
Alamat Rumah
Desa
: .....................................................................................
Kecamatan
: .....................................................................................
Kabupaten
: .....................................................................................
Samalanga ..2012
Yang Mendaftar
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