PEMERINTAH ROVINSI MALUKU UTARA

DINAS PENDIDIKAN DAN KEBUDAYAAN

SEKOLAH MENENGAH ATAS NEGERI 1 KOTA TERNATE
Jln. Ki Hajar Dewantara No. 1 Ternate 97714 TELP/FAX : 3121355 / (0921) 31214355
Email : sman1ternate.53@gmail.com website : www.sman1ternate.sch.id

FORMULIR PENDAFTARAN CALON ANGGOTA

PASUKAN PENGIBAR BENDERA
SMA NEGERI 1 KOTA TERNATE
TAHUN PELAJARAN 2021/2022

Nama Lengkap           : ...................................................................................................

NISN / NIS-N               : ....................................................................................................
Kelas                                : ...................................................................................................
Jenis Kelamin                   : ...................................................................................................
No. Telpon/HP : ...................................................................................................
Keterangan Kesehatan : ...................................................................................................

Nama Orang Tua/Wali : ...................................................................................................

Alamat Orang Tua/Wali : ...................................................................................................
Telp/HP Orang Tua Wali : ...................................................................................................
Pekerjaan Orang Tua/Wali : ...................................................................................................

Pernah Berogranisasi Di : ...................................................................................................

Prestasi Yang Pernah Dicapai : ...................................................................................................
Alasan Masuk Paskibraka : ...................................................................................................

Saya yang bertanda tangan dibawah inimenyatakan mendaftarkan diri sebagai Calon Paskibraka dan akan
Mengikuti segala aturan Paskibaraka SMA Negeri 1 Kota Tetnate

Mengetahui, Ternate, ................................... 2021

Orang/Tua Wali Calon Paskibraka

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