YAYASAN ISLAMIC CENTRE AL MUNAWWARAH KABUPATEN CILACAP

SEKOLAH MENENGAH KEJURUAN

SMK AL MUNAWWARAH CILACAP
Jl. Kutilang No.1 Slarang, Kesugihan Tlp. 0282 5263015, smkalmunawwarah2000@yahoo.co.id 53274

FORMULIR PENDAFTARAN PESERTA DIDIK BARU NO. PENDAFTARAN

(diisi petugas)
SMK AL MUNAWWARAH CILACAP
TAHUN PELAJARAN 2018/2019

A. KETERANGAN DIRI SISWA

1. Nama Lengkap : .........................................................................................................
2. NISN : .........................................................................................................
3. Jenis Kelamin* : Laki-laki Perempuan
4. Tempat, Tanggal Lahir : .........................................................................................................
5. Agama : .........................................................................................................
6. Anak ke : ..............dari ......... bersaudara
7. Status : Anak Yatim / Piatu / Yatim Piatu **
8. Tinggi dan Berat Badan : ..............cm ...............kg
B. KETERANGAN TEMPAT TINGGAL
1. Alamat Lengkap : .........................................................................................................
: .........................................................................................................
No. Telp./HP : .........................................................................................................
2. Alamat Domisili : .........................................................................................................
(Wali/Asrama/Kost) : .........................................................................................................
C. KETERANGAN PENDIDIKAN
1. Asal Sekolah : .........................................................................................................
D. KETERANGAN ORANGTUA/WALI
1. Nama Orang Tua a. Ayah : .........................................................................................................
b. Ibu : .........................................................................................................
2. Alamat Orang Tua : .........................................................................................................
: .........................................................................................................
No. Telp./HP : .........................................................................................................
3. Pekerjaan Orang Tua a. Ayah : .........................................................................................................
b. Ibu : .........................................................................................................
4. Nama Wali : .........................................................................................................
5. Alamat Wali : .........................................................................................................
: ............................................................Telp/Hp................................
6. Pekerjaan Wali : .........................................................................................................
E. PILIHAN PROGRAM STUDI
1. Pilihan 1 (pilihan utama)* : TPTL TKR TKJ Akuntansi
2. Pilihan 2 (pilihan alternatif)* : TPTL TKR TKJ Akuntansi
Keterangan : TPTL = Teknik Pembangkit Tenaga Listrik; TKR = Teknik Kendaraan Ringan
TKJ = Teknik Komputer Jaringan;
F. PRESTASI DI BIDANG AKADEMIK/NON AKADEMIK
JUARA BIDANG TINGKAT
…… ....................................................................... .....................................
…… ....................................................................... .....................................
……
....................................................................... .....................................

G. SUMBER INFORMASI* : Spanduk/Baliho/Pamflet Brosur/Sosialisasi

Rekomendasi dari : ...................................................................

Cilacap, ............................... 2018

Pas Foto Calon Siswa
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Catatan
* Beri tanda check ()
** Coret yang tidak perlu