PEMERINTAH PROVINSI NUSA TENGGARA TIMUR

DINAS PENDIDIKAN
UPT PENDIDIKAN WILAYAH I (KOTA KUPANG, KABUPATEN KUPANG,
TTS)
SMA NEGERI 1 KUPANG
Jl. Cak Doko No. 59 Kupang Telp./Fax. (0380) 821684
Email : infosman1.kupang@gmail.com, Website : www.sman1kupang.sch.id
FORMULIR PENERIMAAN PESERTA DIDIK BARU (PPDB)
SMA NEGERI 1 KUPANG TA. 2017/2018
NO. PENDAFTARAN : PPDBSMAN1 (diisi oleh panitia)
A. KETERANGAN TENTANG DIRI SISWA
1. NISN* : ____________________________ *) Nomor Induk Siswa Nasional (10 digit)
2. NIK* : ____________________________ *) Nomor Induk Kependudukan (di KK)
3. Nama Lengkap Siswa* : __________________________________________________________

__________________________________________________________
4. Tempat dan tanggal lahir* : __________________________________________________________
5. Jenis Kelamin* : 1. Laki-laki 2. Perempuan *) Tandai (X) yang dipilih
6. Agama* : 1. Islam 2. Protestan 3. Katolik 4. Hindu

5. Budha 6. Konghuchu *) Tandai (X) yang dipilih

7. Hobi* : __________________________________________________________
8. Pihak yang dihubungi* : (1) Ayah (2) Ibu (3) Wali Siswa *) Tandai (X) yang dipilih
9. Penanggung biaya* : __________________________________________________________
B. KETERANGAN TEMPAT TINGGAL
1. Alamat Lengkap* : __________________________________________________________

__________________________________________________________
RT* _______ RW* _______ Kode Pos ____________
Kelurahan/desa* : _____________________________
Kecamatan* : _____________________________
Kota* : _____________________________
Propinsi* : _____________________________
2. No Telepon / HP* : _____________________________ , ___________________________
3. Tinggal di* : __________________________________________________________
4. Jarak tempat tinggal ke Sekolah* : ________ km/m (jika jarak kurang dari 1 km, isikan meter)
5. Alat Transportasi ke Sekolah* : (1) Jalan kaki (2) Kend. Pribadi (3) Kend. Umum (4) Ojek

*) Tandai (X) yang dipilih

C. KETERANGAN PENDIDIKAN
1. Asal Sekolah : __________________________________________________________

__________________________________________________________
2. Nomor Ijasah : _________________________________
3. Tanggal Ijasah : _________________________________
4. Lulusan Tahun : ________________
5. Nilai Ujian Nasional :
MATA PELAJARAN JUMLAH NILAI
BINDO BING MAT IPA
 GOVERNMENT OF EAST NUSA TENGGARA PROVINCE
EDUCATION AUTHORITIES
UPT EDUCATION AREA I (KUPANG CITY, KUPANG REGENCY, TTS)
SMA NEGERI 1 KUPANG
Cak Doko Street No. 59 Kupang Telp./Fax. (0380) 821684
Email: infosman1.kupang@gmail.com, Website: www.sman1kupang.sch.id
NEW TRAINING PARTICIPANTS FORM (PPDB)
SMA NEGERI 1 KUPANG TA. 2017/2018

NO. REGISTRATION: PPDBSMAN1 (filled by committee)

A. INFORMATION ABOUT SELF STUDENTS
1. NISN *: ____________________________ *) National Student Number (10 digits)
2. NIK *: ____________________________ *) Population Identity Number (in KK)
3. Full Name Student *: __________________________________________________________

__________________________________________________________
4. Place and date of birth *: __________________________________________________________
5. Gender *: 1. Male 2. Female *) Mark (X) selected
6. Religion *: 1. Islam 2. Protestant 3. Catholic 4. Hinduism
5. Budha 6. Konghuchu *) Mark (X) selected
7. Hobbies *: __________________________________________________________
8. Party contacted *: (1) Father (2) Mother (3) Student Guard *) Mark (X) selected
9. Insurers charge *: __________________________________________________________
B. DESCRIPTION OF THE PLACE TO STAY
1. Full Address *: __________________________________________________________

__________________________________________________________
Neighbourhood* _______ Hamlet * _______ Postal Code ____________
Urban Village *: _____________________________
Districts* : _____________________________
City *: _____________________________
Province *: _____________________________
2. No Phone / HP *: _____________________________, ___________________________
3. Staying at *: __________________________________________________________
4. Distance of residence to School *: ________ km / m (if distance less than 1 km, fill meter)
5. Transportation Equipment to School *: (1) Walking (2 Private Vehicle (3) General Vehicle (4) Ojek

*) Mark (X) selected

C. FACTS OF EDUCATION
1. School Origin: __________________________________________________________

__________________________________________________________
2. Number of Diploma: _________________________________
3. Date of Diploma: _________________________________
4. Year graduates: ________________
5. National Examination Score:
EYES OF LESSON TOTAL VALUE
BINDO ENGLISH MATH SCIENCE