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TAMAN KANAK-KANAK

TK PKK AL-HUSNA
Alamat : RT 06 RW 03 Dusun Krajan Desa Sendang
KECAMATAN NGRAYUN KABUPATEN PONOROGO
Telepon : 085331961303 Kode Pos : 63464

FORMULIR PENDAFTARAN
PENERIMAAN PESERTA DIDIK BARU ( PPDB )
TAHUN PELAJARAN 2021/2022

A. IDENTITAS CALON PESERTA DIDIK


1. Nama Lengkap : .................................................................................
2. NIK : .................................................................................
3 No KK : .................................................................................
4 No Akte Kelahiran : .................................................................................
5 Tempat tanggal Lahir : .................................................................................
6 Alamat : .................................................................................
7 Jenis Kelamin : .................................................................................
8 Agama : .................................................................................
9 Anak Ke : .................................................................................
10 Jumlah Saudara Kandung : .................................................................................

B. IDENTITS ORANG TUA/WALI


1. Ayah kandung/Tiri/Angkat/wali
a. Nama : .................................................................................
b. NIK : .................................................................................
c. Tempat Tanggal Lahir : .................................................................................
d. Agama : .................................................................................
e. Pekerjaan : .................................................................................
f. Pendidikan : .................................................................................

2. Ibu Kandung/Tiri/Angkat/Wali
a. Nama : .................................................................................
b. NIK : .................................................................................
c. Tempat Tanggal Lahir : .................................................................................
d. Agama : .................................................................................
e. Pekerjaan : .................................................................................
f. Pendidikan : .................................................................................

Sendang,...................................2021
Orang Tua/Wali

(...................................................)
*Coret yang tidak perlu

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