KOP MADRASAH

SURAT KETERANGAN PINDAH SEKOLAH/MADRASAH

Nomor : ........................................

Yang bertanda tangan di bawah ini Kepala Sekolah/Madrasah

............................................................ menerangkan bahwa :

Nama :................................................................................
Tempat, Tanggal Lahir :................................................................................
Jenis Kelamin :................................................................................
Nomor Induk Siswa (Lokal) :................................................................................
NISN :................................................................................
Siswa Kelas :................................................................................
NSM Sekolah/Madrasah :................................................................................

Sesuai surat permohonan pindah sekolah/madrasah oleh orang tua / wali murid :

Nama :................................................................................
Alamat :................................................................................

Telah mengajukan pindah sekolah/madrasah ........................................... yang

beralamat di ............................................... dengan alasan
……………………………………..

........................, ...................2018
Kepala Sekolah/Madrasah

....................................................
NIP. ...........................................

Mohon setelah anak diterima di sekolah/madrasah ini, isian ini diisi dan dikirim kembali
kepada kami.

Nama Sekolah/Madrasah : .................................................................................

Desa / Kelurahan : .................................................................................
Kecamatan : .................................................................................
Kabupaten : .................................................................................
Propinsi : .................................................................................
Diterima tanggal : .................................................................................
Di tingkat / kelas : .................................................................................

………………….., …………….…….
Kepala Sekolah/Madrasah