YAYASAN HUFFAZHUSSUNNAH INDONESIA

LEMBAGA TAHFIDZUL QURAN DAN BAHASA ARAB

IBNU ‘UTSMAN TANJUNGPINANG
Alamat : Jln. Damai Kampung Sei Ladi Kel.Kampung Bugis Kec.Tanjungpinang Kota

LEMBAR BIODATA SANTRI

Nomor Induk Santri :.........................................................

Nama Santri : GITA DEVAN LESMANA
Program/Kelas : Hafalan 30 Juz dan Bahasa Arab
Pas Foto

4x6

A. KETERANGAN TENTANG DIRI SANTRI

1. Nama Santri
a. Nama Lengkap : ............................................................................
b. Nama Panggilan/Sapaan : ............................................................................
2. Jenis Kelamin : ............................................................................
3. Tempat/Tanggal Lahir : ............................................................................
4. Kewarganegaraan : ............................................................................
5. Anak Ke - : ............................................................................
6. Jumlah Saudara Kandung : ............................................................................
7. Jumlah Saudara Tiri : ............................................................................
8. Jumlah Saudara Angkat : ............................................................................
9. Anak Yatim/Piatu/Yatim Piatu : ............................................................................
10. Bahasa Sehari-hari di Rumah : ............................................................................

B. KETERANGAN TEMPAT TINGGAL

11. Alamat Lengkap : ............................................................................
............................................................................
12. Nomor Telp./HP. : ............................................................................
13. Tinggal dengan Orang Tua/Saudara/
di Asrama/Kost : ............................................................................
14. Jarak Tempat Tinggal ke Pondok Pesantren : ............................................................................

C. KETERANGAN KESEHATAN
15. Golongan Darah : ............................................................................
16. Penyakit yang Pernah Diderita
(TBC, Cacar, Malaria, dll) : ............................................................................
17. Kelainan Jasmani : ............................................................................
18. Tinggi Badan : ............................................................................
19. Berat Badan : ............................................................................

D. KETERANGAN PENDIDIKAN
20. Pendidikan Sebelumnya
a. Lulus dari : ............................................................................
b. Tanggal dan No. STTB : ............................................................................
c. Lamanya Belajar : ............................................................................
21. Diterima di Pondok Pesantren ini
a. Di Kelas : ............................................................................
b. Tanggal : ............................................................................
 YAYASAN HUFFAZHUSSUNNAH INDONESIA
LEMBAGA TAHFIDZUL QURAN DAN BAHASA ARAB
IBNU ‘UTSMAN TANJUNGPINANG
Alamat : Jln. Damai Kampung Sei Ladi Kel.Kampung Bugis Kec.Tanjungpinang Kota

E. KETERANGAN TENTANG AYAH KANDUNG

22. Nama Lengkap : ............................................................................
23. Tempat/Tanggal Lahir : ............................................................................
24. Agama : ............................................................................
25. Kewarganegaraan : ............................................................................
26. Pendidikan Terakhir : ............................................................................
27. Pekerjaan : ............................................................................
28. Penghasilan per Bulan : ............................................................................
29. Alamat Rumah : ............................................................................
............................................................................
30. No. Telp./HP. : ............................................................................
31. Masih Hidup/Meninggal Dunia : ............................................................................

F. KETERANGAN TENTANG IBU KANDUNG

32. Nama Lengkap : ............................................................................
33. Tempat/Tanggal Lahir : ............................................................................
34. Agama : ............................................................................
35. Kewarganegaraan : ............................................................................
36. Pendidikan Terakhir : ............................................................................
37. Pekerjaan : ............................................................................
38. Penghasilan per Bulan : ............................................................................
39 Alamat Rumah : ............................................................................
............................................................................
40. No. Telp./HP. : ............................................................................
41. Masih Hidup/Meninggal Dunia : ............................................................................

G. KETERANGAN TENTANG WALI (BILA SANTRI TIDAK IKUT DENGAN ORANG TUA)
44. Nama Lengkap : ............................................................................
45. Tempat/Tanggal Lahir : ............................................................................
46. Agama : ............................................................................
47. Kewarganegaraan : ............................................................................
48. Pendidikan Terakhir : ............................................................................
49. Pekerjaan : ............................................................................
50. Penghasilan per Bulan : ............................................................................
51. Alamat Rumah : ............................................................................
............................................................................
52. No. Telp./HP. : ............................................................................
53. Hubungan Keluarga dengan Siswa : ............................................................................

H. KEGEMARAN SANTRI
54. Olahraga : ............................................................................
55. Hobby : ............................................................................
56. Lain-Lain : ............................................................................
Tanjungpinang,...................................
Mengetahui, Tertanda,
Orang Tua/Wali Santri

............................................... ...............................................
(Tanda Tangan dan Nama Jelas) (Tanda Tangan dan Nama Jelas)