BIDANG STUDI : ..........................................................................................
1. Nama Lengkap : ........................................................................................... 2. N I S N : ........................................................................................... 3. Tempat / Tgl. Lahir : ............................./ Tanggal ...... Bulan..............Tahun..... 4. Umur Peserta : ......Tahun ...................... Bulan ..................... Hari ............ 5. Agama : ............................................................................................ 6. Jenis Kelamin : ............................................................................................ 7. Asal Sekolah : ............................................................................................ 8. Alamat Sekolah : Jalan : ............................................................ Desa/Kel : ............................................................ Kec : ............................................................ Kab/Kota : ............................................................ Kode Pos : .........................Telepon: .................... Nama Kepsek : ............................................................ NPSN : ......................................No. HP: ........ E-mail : ............................................................ 9. Kelas : ............................................................................................ 10. Orang tua : Nama Orangtua: Ayah: ........................ Ibu: .................. Pekerjaan : Ayah: .........................Ibu: .................. Alamat Rumah : ............................................................ No. Handphone / WA : ........................E-mail: ................... 11. Prestasi Peserta : ..................................................................................................