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Rumah Aspirasi

Dr.  
  
Ir. Hetifah Sjaifudian, MPP
 
Wakil Ketua Komisi X DPR RI
Cianjur Jl. Jl.
AriaAW SyahranieNo.
Cikondang Gg.52Wangi No.11Sawahgede
Kelurahan RT.14 Kel. Kecamatan
Gunung Kelua, Kec.43212.
Cianjur Samarinda Ulu, Samarinda
Tlp. (0263)2916255
Formulir Pendataan Beasiswa PIP Kaltim

Usulan Dr. Ir. Hetifah Sjaifudian, MPP
  
  
Melalui Kemendikbud RI - 2019
 
Data Siswa :
Nama Siswa : ...................................................................................................
NIK : ...................................................................................................
NISN :...................................................................................................
Tempat/Tanggal lahir : ...................................................................................................
Jenis Kelamin : ...................................................................................................
Kelas : ...................................................................................................
Nomor HP Siswa : ...................................................................................................
Data Sekolah :
Nama Sekolah : ...................................................................................................
NPSN : ...................................................................................................
Alamat Jelas Sekolah : ...................................................................................................
Kecamatan : ...................................................................................................
Kabupaten/Kota : ...................................................................................................
Data Orangtua/Wali :
Nama Ayah atau Ibu : ...................................................................................................
Nomor HP : ...................................................................................................
Nama Wali/Saudara lain : ....................................................................................................
No HP. : ....................................................................................................
Alamat : Jl.................................................. No. .............. RT...................
Desa/Kelurahan : ............................................... Kec. ..........................................
Kab/Kota : ............................................... Prov. .........................................
Wajib :
Update data Dapodik atau mengajukan nama diatas ke Dapodik sekolah dengan keterangan layak Dapodik.
............................, ....... / ....... 
2019
Mengetahui,
Orangtua/Wali, Pemohon,

(......................................) ( .........................................)

Catatan:
- Beasiswa ini Gratis tanpa dipungut biaya
- Penerima beasiswa PIP ini sesuai kriteria dari Kemdikbud.
- Centrang apabila data Dapodik sudah di Update oleh sekolah
- Wajib diisi lengkap data pengajuan diatas

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