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PEMERINTAH PROVINSI SUMATERA SELATAN

DINAS PENDIDIKAN
SEKOLAH MENENGAH ATAS NEGERI 1 PAGARALAM
Jalan Kapten Sanap No. 52 Telp. (0730) 621045

BIODATA
CALON PESERTA DIDIK BARU

1. Nama : ..........................................................................................

2. Tempat/Tanggal Lahir : ..........................................................................................

3. Jenis Kelamin : ..........................................................................................

4. NISN ..........................................................................................

5. Agama : ..........................................................................................

6. No HP : ..........................................................................................

7. Penyakit yang pernah diderita : ..........................................................................................

8. Alamat Rumah siswa :..........................................................................................

9. Asal Sekolah : ..........................................................................................

10. Diterima di kelas : ..........................................................................................

11. Nama Orang Tua : ..........................................................................................

12. Pekerjaan Orang Tua : ..........................................................................................

13. Penghasilan Orang tua : ..........................................................................................

14. Agama Orang Tua : ..........................................................................................

15. Alamat Orang tua : ..........................................................................................

16. Nama Wali : ..........................................................................................

17. Pekerjaan Wali : ..........................................................................................

18. Hubungan Keluarga dengan Wali : ..........................................................................................

19. Alamat Wali : ..........................................................................................

20. Nomor HP orang tua/wali : ..........................................................................................

Pagar Alam, ............................ 2020


Calon Peserta Didik Baru

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(Nama lengkap)

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