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BIODATA PESERTA

KEGIATAN KOMPETISI SAINS NASIONAL (KSN)


SD/MI TINGKAT KOTA BONTANG
TAHUN 2020

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 : ..................................................................................................

Peserta,
PHOTO

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