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Tempat, Tanggal Lahir : ................................................................................... Alamat Lengkap : ................................................................................... Agama : ................................................................................... Asal Sekolah : ................................................................................... Jurusan yang dipilh : ................................................................................... No HP Siswa : ................................................................................... No HP Orangtua : ................................................................................... Ekskul yang dipilih : ................................................................................... Nama Orangtua Ayah : ................................................................................... Ibu : ................................................................................... Pekerjaan Orangtua Ayah : ................................................................................... Ibu : ...................................................................................