PEMERINTAH KABUPATEN SUKABUMI

DINAS PENDIDIKAN
SMP NEGERI 1 CIBADAK
Jalan Siliwangi No. 123 Telp. (0266) 531333 Cibadak Kabupaten Sukabumi
E-Mail : smpn1cbd_kabsi@yahoo.co.id

FORMULIR PENERIMAAN PESERTA DIDIK BARU (PPDB)

SMP NEGERI 1 CIBADAK TAHUN PELAJARAN 2017/2018

Nomor Pendaftaran : ..............................................................

Nama : .................................................................................................
Tempat tanggal lahir : .................................................................................................
Jenis Kelamin : 1. Laki – laki. 2. Perempuan *)
Agama : .................................................................................................
Golongan darah : 1. A, 2 B, 3 O 4 AB *)
Alamat : .................................................................................................
.................................................................................................
.................................................................................................
No. Telepon/HP : .................................................................................................
NISN : .................................................................................................
Asal Sekolah : SD / MI *) .............................................................................
Nama Orang Tua :
Ayah : .................................................................................................
Pendidikan terakhir : .................................................................................................
Pekerjaan : .................................................................................................
Ibu : .................................................................................................
Pendidikan terakhir : .................................................................................................
Pekerjaan : .................................................................................................

Cibadak, ....................................2017
Mengetahui Calon siswa/ pendaftar
Orang Tua/Wali *)

(................................................) (................................................)
*) coret yang tidak perlu

Diisi oleh Pendaftar yang memiliki rengking 1, 2, dan 3 dikelasnya

Nilai Raport
Kelas Rata-
No. Mata Pelajaran Kelas IV Kelas V Jumlah
VI Rata
Smt.1 Smt.2 Smt.1 Smt.2 Smt.1

1. Bahasa Indonesia

2. Matematika

3. IPA

Jumlah

Catatan:
Lampirkan Photo Copy Raport

Cibadak,……………….…2017
Orang Tua/Wali Siswa

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