PEMERINTAH KABUPATEN SUKABUMI

DINAS PENDIDIKAN
Jl. Raya Palabuhan II Km. 22 Ds. Cimanggu Kec. Cikembar
Telp. (0266) 321578 Fax (0266) 321578

BIODATA PESERTA
FESTIVAL DAN LOMBA SENI SISWA NASIONAL (FLS2N – SD)
TINGKAT KABUPATEN SUKABUMI TAHUN 2018

Cabang : ......................................................................................................
Kecamatan : ......................................................................................................
1. Nama Lengkap : ......................................................................................................
2. NISN : ......................................................................................................
3. Tempat/Tgl Lahir : ......................................................................................................
4. Jenis Kelamin : Laki-laki/Perempuan*)
5. Agama : ......................................................................................................
6. Kelas : ......................................................................................................
7. Nama Sekolah : ......................................................................................................
8. Alamat Sekolah :
a. Jalan/Kampung : ......................................................................................................
b. RT/RW : ......................................................................................................
c. Kelurahan/Desa : ......................................................................................................
d. Kecamatan : ......................................................................................................
9. Alamat Rumah :
a. Jalan/Kampung : ......................................................................................................
b. RT/RW : ......................................................................................................
c. Kelurahan/Desa : ......................................................................................................
d. Kecamatan : ......................................................................................................
10. No. Telp Rumah/HP : ......................................................................................................
11. Data Orang Tua/Wali :
a. Nama : ......................................................................................................
b. Pekerjaan : ......................................................................................................
c. No. Telp/HP : ......................................................................................................
Parakansalak, Maret 2018
Mengetahui Peserta
Kepala Sekolah

........................................................... ................................................................
NIP . ....................................................

Keterangan :
 *) coret yang tidak perlu
 Lampiran
a. Photo copy raport lembar identitas dan lembar nilai semester terakhir (legalisir kepala
sekolah)
b. Photo copy akta kelahiran (legalisir kepala sekolah
 PEMERINTAH KABUPATEN SUKABUMI
DINAS PENDIDIKAN
Jl. Raya Palabuhan II Km. 22 Ds. Cimanggu Kec. Cikembar
Telp. (0266) 321578 Fax (0266) 321578

BIODATA OFFICIAL
FESTIVAL DAN LOMBA SENI SISWA NASIONAL (FLS2N – SD)
TINGKAT KABUPATEN SUKABUMI TAHUN 2018

Cabang : ......................................................................................................
Kecamatan : ......................................................................................................
1. Nama Lengkap : ......................................................................................................
2. NISN : ......................................................................................................
3. Tempat/Tgl Lahir : ......................................................................................................
4. Jenis Kelamin : Laki-laki/Perempuan*)
5. Agama : ......................................................................................................
6. NIP/NUPTK : ......................................................................................................
7. Pangkat/Golongan : ......................................................................................................
8. Jabatan : ......................................................................................................
9. Unit Kerja/Instansi : ......................................................................................................
10. Alamat Unit Kerja :
a. Jalan/Kampung : ......................................................................................................
b. RT/RW : ......................................................................................................
c. Kelurahan/Desa : ......................................................................................................
d. Kecamatan : ......................................................................................................
11. Alamat Rumah :
e. Jalan/Kampung : ......................................................................................................
f. RT/RW : ......................................................................................................
g. Kelurahan/Desa : ......................................................................................................
h. Kecamatan : ......................................................................................................
12. No. Telp Rumah/HP : ......................................................................................................
Parakansalak, Maret 2018
Mengetahui Official
Kepala Sekolah

........................................................... ................................................................
NIP . ....................................................
 ALBUM FOTO FLS2N – SD
TAHUN 2018

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

Kecamatan : .........................................................................................................

OFFICIAL/PELATIH
1. Cabang : .............................................................................................
2. Nama Official/Pelatih : .............................................................................................

Pas foto
Ukuran 3 x4
Berwarna
Latar merah

PESERTA
1. Cabang : ..................................................................................................
2. Nama Peserta : ..................................................................................................
3. Kelas : ..................................................................................................

Pas foto Pas foto

Ukuran 3 x4 Ukuran 3 x4
Berwarna Berwarna