PEMERINTAH KABUPATEN SUMEDANG

DINAS PENDIDIKAN
UPT KANTOR DINAS PENDIDIKAN KECAMATAN JATINANGOR
PANITIA FESTIVAL LOMBA SENI SISWA NASIONAL
(FLS2N) TAHUN 2018
Jl. Ir. Soekarno No. 135 Telp. 022-7795359 Kode Pos. 45363

IDENTITAS PESERTA

1. Cabang Lomba : .............................................................................................

2. Nama Lengkap : .............................................................................................

3. Jenis Kelamin : .............................................................................................

4. Tempat, Tgl. Lahir : .............................................................................................

5. Agama : .............................................................................................

6. Kelas : .............................................................................................

7. Nomor Induk Sekolah : .............................................................................................

8. NISN : .............................................................................................

9. Nama Sekolah : .............................................................................................

10. Nama Kepala Sekolah : .............................................................................................

11. Alamat Rumah : .............................................................................................

.............................................................................................
.............................................................................................

12. Nama Orang Tua/Wali : .............................................................................................

13. Pekerjaan Orang Tua/Wali : .............................................................................................

14. Tinggi Badan dan Berat Badan : .... cm .... Kg

Mengetahui ...................................................................
Kepala Sekolah Peserta

( ) ( )
NIP.

Catatan:
Setiap Peserta harap melampirkan photo copy Akta Kelahiran, Kartu Keluarga, Rapor dan 4 buah
Pas photo ukuran 3 x 4
 PEMERINTAH KABUPATEN SUMEDANG
DINAS PENDIDIKAN
UPT KANTOR DINAS PENDIDIKAN KECAMATAN JATINANGOR
PANITIA FESTIVAL LOMBA SENI SISWA NASIONAL
(FLS2N) TAHUN 2018
Jl. Ir. Soekarno No. 135 Telp. 022-7795359 Kode Pos. 45363

IDENTITAS PELATIH

1. Cabang Lomba : .............................................................................................

2. Nama Lengkap : .............................................................................................

3. Jenis Kelamin : .............................................................................................

4. Tempat, Tgl. Lahir : .............................................................................................

5. Agama : .............................................................................................

6. NIP : .............................................................................................

7. NUPTK : .............................................................................................

8. Pangkat/Golongan : .............................................................................................

9. Unit Kerja : .............................................................................................

Jabatan : .............................................................................................

10. Nama Kepala Sekolah : .............................................................................................

11. Alamat Rumah : .............................................................................................

.............................................................................................

.............................................................................................

Mengetahui ...................................................................
Kepala Sekolah Pelatih

( ) ( )
NIP NIP

Catatan:
Setiap pelatih harap Surat Tugas dari kepala sekolah dan 4 buah Pas photo ukuran 3 x 4