YAYASAN PONDOK PESANTREN FALAHUL MUHIBBIN

SEKOLAH MENENGAH KEJURUAN (SMK) ISLAM

MBAH BOLONG
Kompetensi Keahlian : Agribisnis dan Agroteknologi
NO. Ijin Operasional : P2T/34/19.07/01/V/2018
Sekretariat : Dsn. Gendong Ds. Watugaluh Diwek Jombang Jawa Timur Tromol Pos 61471 Tlp. 085806090121
Email : smkislammb@gmail.com

FORMULIR
PENDAFTARAN CALON SISWA BARU
TAHUN PELAJARAN 2018/2019
A. KETERANGAN PRIBADI
1. Nama : ..........................................................................................................
2. Nama Panggilan : ..........................................................................................................
3. Jenis Kelamin : ..........................................................................................................
4. Tempat/ Tanggal Lahir : ..........................................................................................................
5. Golongan darah : ..........................................................................................................
6. Agama : ..........................................................................................................
7. Alamat Asal : ..........................................................................................................
8. Alamat Sekarang : ..........................................................................................................
9. No. Telepon/HP : ..........................................................................................................
10. Jumlah saudara kandung/tiri : ..........................................................................................................
11. Bahasa sehari-hari : ..........................................................................................................

B. PENDIDIKAN
1. Sekolah Asal
2. Ijazah Terakhir
3. Tanggal/ No. STK
4. Alamat Sekolah
5. Lama Belajar
6. Nilai Rata-rata SKHUN
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................

C. ORANG TUA
1. Nama Orang Tua : a. Ayah : ....................................................................................
b. Ibu : .................................................................................
2. Pekerjaan Orang Tua : ..........................................................................................................
3. Keadaan Orang Tua : a. Ayah : Masih Hidup/ Sudah Meninggal
b. Ibu : Masih Hidup/ Sudah Meninggal
4. Alamat Orang Tua : ..........................................................................................................
5. Nama Wali Siswa : ..........................................................................................................
6. Alamat Wali : ..........................................................................................................
7. No. Telepon/HP : ..........................................................................................................

Jombang,……………………….

Mengetahui,
Orang Tua/Wali Calon Siswa,

(………………………………) (……………………………..)

Catatan
- Mengisi Data Pribadi harus sesuai dengan Ijazah / STK / SKHU SMP
- Calon siswa hanya mengisi data bagian atas, tanda tangan wali/ orang tua dan calon siswa