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PEMERINTAH KABUPATEN GARUT


DINAS PENDIDIKAN
SMP N 5 BANJARWANGI
TERAKREDITASI “B”
Kp. Cibengang RT 01 RW 12 Desa Talagasari Kecamatan Banjarwangi

FORMULIR PESERTA DIDIK


TAHUN AJARAN 2020/2021
Tanggal :

DATA PRIBADI PESERTA DIDIK BARU


1. Nama Lengkap : ______________________________________________________________________________
PAS
_______________________________________________________________________________________________________
PHOTO 3 X 4
2. Jenis kelamin :_______________________________________________________________________________

3. NISN :_______________________________________________________________________________

4. NIK :_______________________________________________________________________________

5. Tempat, Tanggal Lahir :_______________________________________________________________________________

6. No. Akta Kelahiran :______________________________________________________________________________

7. Agama :______________________________________________________________________________

8. Alamat Rumah :_______________________________________________________________________________

9. Nama Dusun/Desa :_______________________________________________________________________________

10. Kecamatan :_______________________________________________________________________________

11. Kode POS :_______________________________________________________________________________

12. Nomor KIP :_______________________________________________________________________________

13. Nama di KIP :_______________________________________________________________________________

14. Asal Sekolah (SD/MI) :_______________________________________________________________________________

15. Nomor KKS/KPS :_______________________________________________________________________________

16. Anak Ke (KK) :_______________________________________________________________________________

17. Nama Ayah Kandung :_______________________________________________________________________________

18. Pekerjaan :_______________________________________________________________________________

19. Nama Ibu Kandung :_______________________________________________________________________________

20. Nomor HP :_______________________________________________________________________________

21. Jumlah Saudara :_______________________________________________________________________________

LAMPIRAN DAN BERKAS LAINNYA

22. Surat Tanda Kelulusan


23. KK
24. KIP/KKKS/KPS
25. Akte Kelahiran
Copyright smpn5banjarwangi_2020/conversion/tmp/activity_task_scratch/526620376.docx

26. Pas Poto 2X3, 3X4,