YAYASAN PENDIDIKAN ISLAM

MADRASAH ALIYAH AL AMIN

GARAHAN – SILO – JEMBER
NSM : 131235090082 NPSN : 69881451
JL. Banyuwangi No.29 Garahan - Silo – Jember Tlp 087 884 444 411
Email : madrasah.alamin1@gmail.com Kode pos : 68184

FORMULIR NO. REGISTRASI

PENDAFTARAN CALON SISWA BARU

A. KETERANGAN PRIBADI
1. Nama
2. Nama Panggilan
3. Jenis Kelamin
4. Tempat/ Tanggal Lahir
5. Golongan darah
6. Agama
7. Alamat Asal
8. Alamat Sekarang
9. No. Telepon/HP
10. Jumlah saudara kandung/tiri :
11. Bahasa sehari-hari
B. PENDIDIKAN
1. Sekolah Asal
2. Ijazah Terakhir
3. Tanggal/ No. STK
4. Alamat Sekolah
5. Lama Belajar
6. Nilai Rata-rata SKHUN
C. ORANG TUA
1. Nama Orang Tua
2. Pekerjaan Orang Tua
3. Keadaan Orang Tua
4. Alamat Orang Tua
5. Nama Wali Siswa
6. Alamat Wali
7. No. Telepon/HP
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: a. Ayah : ....................................................................................
b. Ibu: .................................................................................
: ..........................................................................................................
: a. Ayah: Masih Hidup/ Sudah Meninggal
b. Ibu : Masih Hidup/ Sudah Meninggal
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................
: ..........................................................................................................

D. SYARAT-SYARAT DAN YANG DILAMPIRKAN

1. Persyaratan Tetap :
No Syarat-syarat Banyak Ada Tidak Ada
1 Foto copy Ijazah dan SKHUN yang dilegalisir 2 Lembar
2. Pas Photo ukuran 3x4 Cm hitam putih 2 Lembar
3. Fotocopy KK 2 Lembar
4. Fotocopy KTP kedua Orang Tua 1 Lembar
5. Fotocopy PIP, PKH dan KPS ( bagi yang memiliki ) 1 Lembar
2. Test Fisik
No. Keadaan Fisik Data Fisik Keterangan
1. Tato Ya Tidak
2. Tindik Ya Tidak
3. Tinggi Badan ... Cm.
4. Berat Badan ... Kg.
Catatan
- Mengisi tabel/ Kolom ada/ tidak ada adalah panitia PSB
- Mengisi Data Pribadi harus sesuai dengan Ijazah / STK / SKHU SMP/MTS
- Calon siswa hanya mengisi data bagian atas, tandatangan wali/ orangtua dan calon siswa
Jember, ..........................................................
Mengetahui,
Orang Tua/Wali Calon Siswa,

(………………………………) (……………………………..)