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OLIMPIADE OLAHRAGA SISWA NASIONAL TINGKAT SMA

KABUPATEN CIANJUR TAHUN 2019

IDENTITAS ATLET

FOTO 3 X 4

1. NAMA : ...........................................................................................................

2. NISN : ...........................................................................................................

3. JENIS KELAMIN : ...........................................................................................................

4. TEMPAT TANGGAL LAHIR : ...........................................................................................................

5. AGAMA : ...........................................................................................................

6. KELAS : ...........................................................................................................

7. SEKOLAH : ...........................................................................................................

8. NAMA PEMBIMBING / PELATIH : ...........................................................................................................

9. NO.HP PEMBIMBING / PELATIH : ...........................................................................................................

10. NAMA ORANG TUA / WALI : ...........................................................................................................

11. ALAMAT RUMAH : ...........................................................................................................

12. CABANG OLAHRAGA : ...........................................................................................................

13. NOMOR YANG DIIKUTI : ...........................................................................................................

Cianjur, ..... April 2019


Mengetahui,
Kepala SMA ................. Atlet,

................................................ ................................................
NIP. NISN.
PERSYRATAN PESERTA O2SN SMA 2019
YANG HARUS DIKUMPULKAN:

1. SURAT KETERANGAN DARI SEKOLAH


2. FC IJAZAH SMP DI LEGALISIR 1 Lembar /
FC AKTE KELAHIRAN 1 Lembar
3. FOTO 3X4 1 Lembar

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