FORMULIR DAFTAR ULANG

DATA POKOK CALON PESERTA DIDIK

TAHUN PELAJARAN 2020 / 2021

Jalur Pendaftaran : Zonasi Prestasi Afirmasi Perpindahan

Nama Lengkap : ........................................................................................…….....................

Jenis Kelamin : .....................................................................................................................
NISN ( Wajib Di isi) : .....................................................................................................................
NIK ( Sesuai KK ) : .....................................................................................................................
Tempat Tanggal Lahir : .....................................................................................................................
Agama : .....................................................................................................................
Alamat Lengkap : ..................................................................................RT: ........ RW: .........
Gang: ...................................... Desa…………… .......................................
Kecamatan:............................................................ Kode Pos : ....................
Asal Sekolah SD : .....................................................................................................................
No HP Siswa : .....................................................................................................................

NILAI 5 SEMESTER MULAI KELAS 4 SD SAMPAI 6 SD

No Mata Pelajaran Kelas 4 Kelas 5 Kelas 6 Jumlah Rata- Rata

I II I II I
1 Bahasa Indonesia
2 Matematika
3 IPA

DATA ORANG TUA SISWA ( AYAH )

Nama Ayah : ................................................... Tgl Lahir : …………………………….
Pendidikan Ayah : ................................................... NIK : …………………………….
Pekerjaan Ayah : ................................................... No.HP : …………………………….

Alamat Orang Tua : ............................................................................. RT: ........ RW: ..............

Gang: ....................................... Desa/Kelurahan: .......................................
Kec. ...................................................................... Kode Pos : ....................

DATA ORANG TUA SISWA ( IBU )

Nama Ibu Kandung : .................................................... Tgl Lahir : …………………………….

Pendidikan Ibu : .................................................... NIK : …………………………….
Pekerjaan Ibu : .....................................................No.HP : …………………………….
Alamat Orang Tua : ............................................................................. RT: ........ RW: ..............
Gang: ....................................... Desa/Kelurahan: .......................................
Kec. ...................................................................... Kode Pos : ....................
DATA ORANG TUA WALI
Nama Ibu Kandung : .................................................... Tgl Lahir : …………………………….
Pendidikan Ibu : .................................................... NIK : …………………………….
Pekerjaan Ibu : .................................................... No.HP : …………………………….
Alamat Orang Tua : ............................................................................. RT: ........ RW: ..............
Gang: ....................................... Desa/Kelurahan: .......................................
Kec. ...................................................................... Kode Pos : ....................

Sungai Raya, Juli 2020

Orang Tua Siswa Dari………………….
PAS PHOTO PAS PHOTO
3 X4 3 X4

………………………………………………