PEMERINTAH KABUPATEN KOLAKA TIMUR

DINAS PENDIDIKAN KEPEMUDAAN DAN OLAHRAGA

SMP NEGERI 2 LADONGI
Jl. Taman Siswa No. 03 Kel. Ra-raa Kec. Ladongi Kab. Kolaka Timur 93573

FORMULIR PENDAFTARAN PESERTA DIDIK BARU (PPDB)

TAHUN PELAJARAN 2020/2021

A. IDENTITAS SISWA BARU

1. Nama Lengkap (Sesuai Ijazah) : ............................................................................
2. Jenis Kelamin : ............................................................................
3. Tempat, Tanggal Lahir : ............................................................................
4. Agama : ............................................................................
5. Status dalam Keluarga : ............................................................................
6. Anak Ke : ............................................................................
7. Alamat Sekarang : ............................................................................
8. Sekolah Asal : ............................................................................
a. Nama Sekolah : ............................................................................
b. Alamat Sekolah : ............................................................................
9. Nomor NISN : ............................................................................
10. Tahun Lulus : ............................................................................
11. Nilai Rata-rata SKHU Sementara : ............................................................................

B. IDENTITAS ORANG TUA

1. Nama Ayah : ............................................................................
2. Nama Ibu : ............................................................................
C. ALAMAT ORANG TUA : ............................................................................
D. NOMOR TELEPON ORANG TUA : ............................................................................
E. PEKERJAAN ORANG TUA
1. Ayah : ............................................................................
2. Ibu : ............................................................................

F. IDENTITAS WALI SISWA

1. Nama : ............................................................................
2. Tempat, Tanggal Lahir : ............................................................................
3. Agama : ............................................................................
4. Pekerjaan : ............................................................................
5. Alamat Sekarang : ............................................................................
6. Nomor Telpon

Ra-raa, Juni 2020

Orang Tua Siswa/ Wali Calon Siswa Baru

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