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BIODATA PESERTA

O2SN SD TINGKAT KOTA BEKASI


TAHUN 2019

HARAP DIISI DENGAN HURUF KAPITAL

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


Jenis Kelamin : L/ P
Tempat/Tanggal Lahir : ............................................................................................
NISN : ............................................................................................
Agama : ............................................................................................
Asal Sekolah : ............................................................................................
NPSN : ............................................................................................
Kelas : ............................................................................................
Cabang Lomba : ............................................................................................
Kategori Lomba : ............................................................................................
Asal Klub : ............................................................................................
Berat Badan : ...........Kg
Tinggi Badan : ...........Cm
Alamat Sekolah : ............................................................................................
............................................................................................
Kab./Kota : ............................................................................................
Provinsi : ............................................................................................
Telepon Sekolah : ............................................................................................
Email Sekolah : ............................................................................................
Alamat Rumah : ............................................................................................
Alamat Sekolah : ............................................................................................
Telepon Rumah / HP : ............................................................................................
Email Pribadi : ............................................................................................
Nama Orang Tua : Ayah …………................... Ibu .........................................
Pekerjaan Orang Tua : Ayah …………................... Ibu .........................................
Prestasi : ............................................................................................

Bekasi, …………………… 2019

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