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KEMENTERIAN AGAMA

DINIYAH AL-IKHLAS
PULO LON
KECAMATAN GLUMPANG TIGA KABUPATEN PIDIE
Jln. Lambaro – Glp Payong No. 8

Nomor Pendaftaran FORMULIR PENDAFTARAN MURID BARU


TAHUN PELAJARAN 20 /20

1. Nama Murid : ..........................................................................................


2. Jenis Kelamin : ..........................................................................................
3. Tempat / Tgl. Lahir : ...........................................................................................
4. Anak Ke :............................................................................................
5. Jumlah Saudara : ..........................................................................................
a. Saudara Kandung :...........................................................................................
b. Saudara Tiri :...........................................................................................
6. Alamat : ..........................................................................................
7. Orang Tua : ..........................................................................................
a. Nama : Ayah..................................Ibu.........................................
b. Pekerjaan : Ayah..................................Ibu.........................................
c. Agama : Ayah..................................Ibu.........................................
d. Pendidikan Terakhir : Ayah..................................Ibu.........................................
e. Alamat : Ayah..................................Ibu.........................................
8. Nama Wali : ...........................................................................................
9. Pekerjaan :............................................................................................
10. Alamat :............................................................................................
11. Masuk Madrasah Ini :............................................................................................
a. Tanggal :............................................................................................
b. Masuk Kelas :............................................................................................
12. Pendapatan Orang Tua : a ≥ 2.000.000,- b. ≥ 1.000.000,- c. ≥ 500.000,-
13. No. Hp :...........................................................................................

Catatan :
1. Membayar uang pendaftaran : Rp. 10.000,-
2. SPP bulan pertama : Rp. 10.000,-
3. Pas Photo 3 x 4 : 4 Lembar

Mengetahui Glumpang Minyeuk


PIMPINAN DINIYAH Orang Tua Wali Siswa

ZULKARNAIN, S.Ag (.................................................)