NATURAL SCIENCE OLYMPIAD IX

NATURAL SCIENCE
SMP & MTsOLYMPIAD
se-Jawa VII
Menumbuhkan Jiwa Saintis Melalui Kompetisi Inovatif
Guna Mewujudkan Literasi Sains Indonesia
FORMULIR PENDAFTARAN
NATURAL SCIENCE OLYMPIAD IX
TINGKAT SMP/MTs se-JAWA

A. Data Pribadi
Nama Lengkap : ....................................................................................
Tempat, Tanggal lahir : ....................................................................................
Jenis Kelamin : ....................................................................................
Kelas : ....................................................................................
Alamat Rumah : ....................................................................................
No. Telp/ Hp : ....................................................................................

B. Data Sekolah
Asal Sekolah : ....................................................................................
Alamat Sekolah : ....................................................................................
No. Telp. : ....................................................................................
Email : ....................................................................................

C. Data Pendamping
Nama Lengkap : ....................................................................................
No. Telp./Hp : ....................................................................................

Pilih rayon dengan tanda centang(√) pada kolom di bawah ini

Semarang Solo Jawa Barat (Tasikmalaya)
Purwokerto Magelang Jawa Timur (Ponorogo)
Pekalongan Yogyakarta Jawa Timur (Tuban)
Kudus Cirebon

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Pas Foto Peserta

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HIMA IPA TERPADU

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