LEMBAGA PENDIDIKAN MA’ARIF NU KENDAL

SMP NU 09 ROWOSARI
Jl. Bahari Barat Gempolsewu Kec. Rowosari Kendal 51354 Telp. 0294-642344

FORMULIR PENERIMAAN PESERTA DIDIK BARU

TAHUN PELAJARAN 2021/2022
A. KETERANGAN CALON PESERTA DIDIK
1. Nama Lengkap : ...............................................................................................................................
2. NIK/ Nomor Induk Keluarga : ........................................................................................................ (16 angka).
3. Jenis Kelamin : ( Laki-laki / Perempuan )*.
4. NISN / Nomor Induk Siswa Nasional : ..................................................................................................... (10 angka).
5. Tempat, Tgl. Bln. Thn. Lahir : ...............................................................................................................................
6. Agama : ...............................................................................................................................
7. Anak ke : .................. (........................................).
8. Status dalam Keluarga : ( Anak Kandung / Anak Tiri / Anak Angkat )*.
9. Alamat Tempat Tinggal : ............................................. RT. ........... RW. ............ Ds. .............................
Kec. ........................................................ Kab. .................................................
10. No. Telp. / Hp. yang bisa dihubungi : ...............................................................................................................................
11. Alumni dari SD / MI Asal : ...............................................................................................................................
12. Jumlah Nilai Akhir dan Nilai Rata-rata : Jumlah NA = .........................., Nilai Rata-rata = .................................
B. KETERANGAN ORANG TUA KANDUNG
1. Nama Lengkap
a. Ayah : ...............................................................................................................................
b. Ibu : ...............................................................................................................................
2. Tempat, Tgl. Bln. Thn. Lahir
a. Ayah : ...............................................................................................................................
b. Ibu : ...............................................................................................................................
3. Pekerjaan
a. Ayah : ...............................................................................................................................
b. Ibu : ...............................................................................................................................
4. Alamat Tempat Tinggal : Jln. ................................... RT. ......... RW. ......... Ds. ...................................
Kec. .................................................... Kab. ....................................................
C. KETERANGAN WALI
1. Nama Lengkap : ..............................................................................................................................
2. Jenis Kelamin : ( Laki-laki / Perempuan )*.
3. Tempat, Tgl. Bln. Thn. Lahir : ..............................................................................................................................
4. Agama : ..............................................................................................................................
5. Pekerjaan : ...............................................................................................................................
Alamat Tempat Tinggal : ............................................. RT. ........ RW. ........ Ds. ...................................
Kec. ..................................................... Kab. ....................................................
6. ............................................................................

7.

NOMOR PENDAFTARAN Diketahui oleh Rowosari, ............................ 2021

Diisi oleh Panitia PPDB, Orang Tua / Wali Murid CPD, Calon Peserta Didik,

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