1. NISM/NISN : ................................................
2. Nama Siswa : ................................................
3. Tempat/Tanggal lahir : ................................................
4. Jenis Kelamin : ................................................
5. Agama : ................................................
6. Kelas : ................................................
7. Nama Orang Tua : ................................................
8. Alamat : ................................................
9. Tanggal mulai pindah : ................................................
10. Mutasi pindah karena : Permintaan Orang tua
11. Pindah ke : ................................................
12. Catatan/Keterangan :-
....................................... 2017
Kepala MTs .........................
...................................................
NIP . -