YAYASAN ROBITHOTUL MA’AHID (YAROBI)

SMK IZZUL ISLAM SALEM

Jl. KH. Izzudin No. 01 Ganggawang, Salem, Brebes 52275

FORMULIR PENDAFTARAN
CALON SISWA BARU SMK IZZUL ISLAM SALEM
TAHUN PELAJARAN 2010/2011

1. Nama : .........................................................................................................
2. Nomor Pendaftaran : 00.../SMK.I/2010
3. Jenis Kelamin : .........................................................................................................
4. Tempat & Tanggal Lahir : .........................................................................................................
5. Agama : .........................................................................................................
6. Alamat Calon Siswa : .........................................................................................................
.........................................................................................................
7. Asal Sekolah
a. Nama Sekolah : .........................................................................................................
b. Alamat Sekolah : .........................................................................................................
8. Surat Tanda Tamat Belajar/Ijazah/Surat Tanda Kelulusan/Surat Tanda Lulus
a. Tahun : .........................................................................................................
b. Nomor : .........................................................................................................
9. Bidang Studi Keahlian yang dipilih dicontreng ()
a. Teknik Otomotif
b. Teknik Komputer dan Informatika
10. Nama Orang Tua
b. Ayah : .........................................................................................................
b. Ibu : .........................................................................................................
11. Alamat Orang Tua : .........................................................................................................
.........................................................................................................
12. Pekerjaan Orang Tua : .........................................................................................................
13. Nama Wali : .........................................................................................................
14. Alamat Wali : .........................................................................................................
.........................................................................................................
15. Pekerjaan Wali : .........................................................................................................

Ganggawang, ............................2010
Calon Siswa,

.......................................
...........................................................................................................................................................

NO. 001
Telah diterima dari : .........................................................................................................
Uang Sebanyak : Dua puluh lima ribu rupiah
Untuk Pembayaran : Pendaftaran Siswa baru SMK IZZUL ISLAM SALEM
Ganggawang, ............................2010
Panitia PSB,

.......................................
Terbilang : Rp. 25.000,00
 YAYASAN ROBITHOTUL MA’AHID (YAROBI)
SMK IZZUL ISLAM SALEM
Jl. KH. Izzudin No. 01 Ganggawang, Salem, Brebes 52275

(Diisi Petugas)
FORMULIR PENDAFTARAN
CALON SISWA BARU SMK IZZUL ISLAM SALEM
TAHUN PELAJARAN 2010/2011

I. Identitas Calon Siswa Baru

1.Nama Lengkap : .............................................................................................
2.Nomor Pendaftaran : 00..../PSB/SMK.I/2010
3.Jenis Kelamin : .............................................................................................
4.Tempat & Tanggal Lahir : .............................................................................................
5.Agama : .............................................................................................
6.Alamat Calon Siswa : .............................................................................................
7.Asal Sekolah : .............................................................................................
8.No STTB/ Tahun Lulus : .............................................................................................
9.Nama Orang Tua/Wali : .............................................................................................
10. Pekerjaan Orang Tua/Wali : .............................................................................................
11. Alamat Orang Tua/Wali : .............................................................................................
12. No. Telp./Hp. : .............................................................................................

II. Persyaratan yang harus dilengkapi

No Jenis Kelengkapan Lembar Paraf Keterangan
1. Photo copy Nilai UN SLTP/MTS yang 2
sudah dilegalisir
2. Photo copy Izajah SLTP/MTS yang sudah 2
dilegalisir
3. Photo copy akte kelahiran 1
4. Photo copy raport semester 5/6 1
5. Surat Kelakuan Baik dari Sekolah 1

III. Keuangan SMK

No Administrasi Jumlah Paraf Keterangan
1. Pendaftaran Rp. 25.000,00
2. DPPM Rutin 2 Bulan (Juli-Agustus 2010) Rp. 160.000,00
3. Kegiatan OSIS 1 Tahun Rp. 50.000,00
4. DPPM Pengembangan Rp. 200.000,00
5. Masa Orientasi Siswa (MOS) Rp. 30.000,00
6. Pakaian Praktek (werpak) Rp. 125.000,00
7. Kaos Olahraga Rp. 60.000,00
8. Seragam Khusus Rp. 50.000,00
9. Atribut Rp. 30.000,00
10. Administrasi Raport Rp. 30.000,00
11. Perawatan Bengkel Rp. 100.000,00
Jumlah Rp. 860.000,00

Ganggawang, ............................2010
Panitia PSB, Calon Siswa,

_____________________ _____________________
(Tanda Tangan dan Nama Jelas) (Tanda Tangan dan Nama Jelas)