Diisi dan diserahkan kepada Panitia

OSN SD pada saat registrasi

BIODATA SISWA/PESERTA
OSN SD TAHUN 2019

CABANG OLIMPIADE : MATEMATIKA / SAINS IPA *)

A. IDENTITAS PRIBADI
Nama Lengkap : .............................................................................
Tempat Tgl. Lahir : .............................................................................
NISN : .............................................................................
Agama : .............................................................................
Kelas : .............................................................................
NO Tlp : .............................................................................
Alamat Rumah : Jalan / Kp. ..........................................................................................
Desa / Kelurahan ...............................................................................
Kecamatan ........................................................................................
Kabupaten / Kota. .............................................................................

B. IDENTITAS SEKOLAH
Nama Sekolah : .............................................................................
NPSN / NSS : .............................................................................
Alamat Sekolah : Jalan / Kp. ..........................................................................................
Desa / Kelurahan ...............................................................................
Kecamatan ........................................................................................
Kabupaten / Kota. .............................................................................

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Guru Pembimbing, Siswa /Peserta/Pendaftar,

Foto
............................................... 3x4 .......................................................
NIP. NISN.

Mengetahui :
Kepala Sekolah,

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