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BIODATA PESERTA KSM 2019

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NAMA SISWA LENGKAP :
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NISN :
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JENIS KELAMIN : LAKI – LAKI / PEREMPUAN*
KOMPETISI* : 1. MATEMATIKA TERINTEGRASI
( KURUNG KOMPETISI YG DIPILIH ) 2. BIOLOGI TERINTEGRASI
3. FISIKA TERINTEGRASI
4. KIMIA TERINTEGRASI
5. EKONOMI TERINTEGRASI
6. GEOGRAFI TERINTEGRASI
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TEMPAT LAHIR :
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TANGGAL LAHIR (DD-MM-YYYY) :
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KELAS / PROGRAM ( X-IPA) :
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EMAIL* :
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HANDPHONE* :
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PRESTASI YG PERNAH DIRAIH :
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ALAMAT LENGKAP :
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( DSN. KRAMAT RT.003/ RW.001 DESA
MARON KIDUL KEC. MARON KAB.
PROBOLINGGO )
PROBOLINGGO, JUNI 2019
PESERTA,

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(TTD & NAMA TERANG)

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