1. NAMA LENGKAP :.....................................................................................................
2. NAMA PANGGILAN :..................................................................................................... 3. TEMPAT & TANGGAL LAHIR :..................................................................................................... 4. UMUR :..................................................................................................... 5. JENIS KELAMIN :..................................................................................................... 6. AGAMA :..................................................................................................... 7. NAMAORANG TUA A. AYAH : ................................................................................................... B. IBU :..................................................................................................... 8. PEKERJAAN ORANG TUA A. AYAH :..................................................................................................... B. IBU :..................................................................................................... 9. ALAMAT :..................................................................................................... ...................................................................................................... 10. NO. TELEPON :..................................................................................................... 11. HOBI :..................................................................................................... 12. CITA – CITA :.....................................................................................................
Orang Tua
Mohon dilampiri dengan :
1. Foto copy Akte Kelahiran / Surat Kenal Lahir (3 lembar) 2. Foto copyKartu Keluarga (KK) (3 lembar) 3. Foto ukuran 3x4 (3 lembar)