CATATAN PRIBADI SISWA SDN SRENGSENG 01 PAGI

KECAMATAN KEMBANGAN JAKARTA BARAT

TAHUN PELAJARAN 20 / 20

A. Nomor Induk : ....................................................................................................

Nama Lengkap Anak : ....................................................................................................
Nama Panggilan : ....................................................................................................
Jenis Kelamin : ....................................................................................................
Tempat /Tgl.Lahir : ....................................................................................................
Anak Ke : ....................................................................................................
Agama : ....................................................................................................
Jmlh Saudara : ....................................................................................................
Bahasa Ibu : ....................................................................................................
Alamat Lengkap : ....................................................................................................
....................................................................................................
Telp ............................................................................................

B. Nama Ayah : .....................................................................................................

Ayah Kandung /Tiri / Wali : .....................................................................................................
Tempat Tgl Lahir : .....................................................................................................
Pendidikan Tertinggi : ....................................................................................................
Agama : .....................................................................................................
Pekerjaan : ....................................................................................................
Nama Kantor : ....................................................................................................
Alamat : ....................................................................................................
Tlep ............................................................................................
Bangsa /Suku Bangsa : .....................................................................................................
Alamat Rumah Lengkap : ....................................................................................................
Rt .....................Rw.................No.......
Telp. .............................................................................................

C. Nama Ibu : ....................................................................................................

Ibu.Kandung /Tiri /Wali : ....................................................................................................
Tempat / Tgl.Lahir : ....................................................................................................
Pendidikan Tertinggi : ....................................................................................................
Agama : ....................................................................................................
Pekerjaan : ....................................................................................................
Nama Kantor : ....................................................................................................
Alamat Kantor : ....................................................................................................
Telp. ............................................................................................
Bangsa /Suku Bangsa : ....................................................................................................
Alamat Rumah Lengkap : ....................................................................................................
Rt .....................Rw.................No.......
Telp. .............................................................................................

NB: Mohon diisi dan segera di kembalikan ke sekolah

Lampirkan 2 lembar foto copy akte kelahiran
Lampirkan foto copy STTB TK (khusus kelas 1) sebanyak 2 lembar
Kartu keluarga sebanyak 2 lembar
Jakarta,

Orang tua wali