BIODATA SISWA X MIPA 4

TAHUN PELAJARAN 2018-2019

1. KETERANGAN PRIBADI
a. Nama Peserta didik :
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b. No Induk :
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c. Jenis Kelamin :
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d. NISN : ...........................................................................................................................................
e. Tempat, tanggal Lahir :
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f. Agama : ...........................................................................................................................................
g. Anak ke- :
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h. Jumlah Saudara Kandung :
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2. KETERANGAN TEMPAT TINGGAL
a. Kampung : .....................................................................................RT:............. RW :.........
b. Desa : ...........................................Kecamatan :
.......................................Kabupaten............................................
c. Tinggal Bersama :
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3. KETERANGAN KESEHATAN
a. Berat Badan :
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b. Tinggi Badan :
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c. Golongan Darah :
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d. Penyakit yang Pernah Diderita :
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4. KETERANGAN PENDIDIKAN SEBELUMNYA
a. Asal Sekolah
a) SLTP/MTS :
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b) Tanggal dan No STTB :
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c) Diterima di Sekolah :
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b. Pindahan dari Sekolah.
a) SLTP/MTS :
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b) Diterima Tanggal :
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c) Di Kelas :
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d) Alasan Pindah Sekolah :
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5. KETERANGAN
a. Hobby :
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b. Cita-cita :
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c. No HP aktif :
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d. E-mail :
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e. FB :
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f. Uang jajan per hari :
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g. Jurusan yang diminati :
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6. KETERANGAN ORANG TUA
a. Nama Ayah Kandung :
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b. Nama Ibu Kandung :
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c. Alamat
a) Kampung : .................................................................................RT :............. RW
:...............
b) Desa : ...........................................Kecamatan :
..................................Kabupaten..............................
c) No Telepon :
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 d. Pekerjaan Ayah :
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Pekerjaan Ibu :
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e. Penghasilan Ayah :
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Penghasilan Ibu :
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f. Pendidikan Tertinggi Ayah :
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Pendidikan Tertinggi Ibu :.....................................
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7. KETERANGAN WALI
a. Nama Wali :
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b. Alamat
a) Kampung : .................................................................................RT :............. RW
:...............
b) Desa : ...........................................Kecamatan :
..................................Kabupaten..............................
c) No Telepon ............................................................................................................................................
c. Pekerjaan Wali :
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