Kab.

Kediri – Jatim (085707910905)

Jl. RA. Kartini No. 27 RT/RW 002/003 Dsn. Padangan Ds. Pagu Kec. Pagu

FORMULIR PENDAFTARAN

A. DATA SISWA
1. Nama : ........................................................................................................................
2. Tempat, tanggal lahir : ........................................................................................................................
3. Agama : ........................................................................................................................
4. Kelas&Sekolah : ........................................................................................................................
5. Alamat : ........................................................................................................................
6. No. HP siswa : ........................................................................................................................
7. Keluhan : ........................................................................................................................

B. DATA ORANG TUA

1. Nama Ayah : ........................................................................................................................
2. Pekerjaan & pendidikan terakhir Ayah : ............................................................................................
3. Nama Ibu : ........................................................................................................................
4. Pekerjaan & pendidikan terakhir Ibu : ...............................................................................................
5. No. HP Ayah/Ibu : ........................................................................................................................

C. PROGRAM BIMBEL YANG DIIKUTI

(Lingkari nomor yang dipilih [O])
1. Jenjang : 1. SD/MI 2. SMP/MTs 3. SMA/MA
2. Mapel : 1. Umum 2. MM 3. B.Inggris 4. Komputer 5. Siap UN
3. Jenis Bimbel : 1. Privat 2. Kelompok

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