PANITIA PENERIMAAN PESERTA DIDIK BARU (PPDB)

MADRASAH DINIYAH YAYASAN PERGURUAN ISLAM

NUSANTARA AL-HUDA (YASPINA)
TAHUN AJARAN 2021-2022
Sekretariat: Jl. Lintas Timur Blok A RW.01/RT.03 Ds. Surya Adi Kecamatan Mesuji Kabupaten Ogan Komering Ilir

FORMULIR DAFTAR ULANG Diisi Panitia

No.
1. Nama : ...............................................................................................
2. Jenis Kelamin : ...............................................................................................
3. Tempat, Tanggal Lahir : ...............................................................................................
4. Anak Ke : ...............................................................................................
5. Jumlah Saudara Kandung : ...............................................................................................
6. Alamat
RT/RW/Desa : ...............................................................................................
No. Rumah : ...............................................................................................
Kecamatan : ...............................................................................................
Kabupaten : ...............................................................................................
Provinsi : ...............................................................................................
7. Asal Sekolah
Lulus/Belum Lulus : ...............................................................................................
8. Prestasi yang pernah diraih : ...............................................................................................
9. Nama Orang Tua
a. Ayah : ...............................................................................................
b. Ibu : ...............................................................................................
10. Pendidikan Orang Tua
a. Ayah : ...............................................................................................
b. Ibu : ...............................................................................................
11. Pekerjaan Orang Tua
a. Ayah : ...............................................................................................
b. Ibu : ...............................................................................................
12. Alamat Orang Tua
RT/RW/Desa : ...............................................................................................
No. Rumah : ...............................................................................................
Kecamatan : ...............................................................................................
Kabupaten : ...............................................................................................
Provinsi : ...............................................................................................
13. Nama Wali : ...............................................................................................
14. Pekerjaan Wali : ...............................................................................................
15. Alamat Wali
RT/RW/Desa : ...............................................................................................
No. Rumah : ...............................................................................................
Kecamatan : ...............................................................................................
Kabupaten : ...............................................................................................
Provinsi : ...............................................................................................

Surya Adi, ……………., 20…

Orang tua/Wali
Ket. : * Diisi dengan huruf yang jelas
* Coret yang tidak perlu

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