NSS/NSM : ………………………………………………………………………………………………………………………….
NPSN : ………………………………………………………………………………………………………………………….
STATUS : NEGERI/SWASTA
AKREDITASI : ………………………………………………………………………………………………………………………….
ALAMAT : ………………………………………………………………………………………………………………………….
ISLAM : ………………………………………………………………………………………………………………………….
KATOLIK : ………………………………………………………………………………………………………………………….
PROTESTAN : ………………………………………………………………………………………………………………………….
HINDU : ………………………………………………………………………………………………………………………….
BUDHA : ………………………………………………………………………………………………………………………….
KONGHUCU : ………………………………………………………………………………………………………………………….
NIP.