PEMERINTAH KABUPATEN GARUT

DINAS PENDIDIKAN
UPTD PENDIDIKAN KEC. CIBALONG
SDN MEKARSARI O4 CIBALONG
Jl. Bangbayang – Mekarsari – Cibalong – Garut – 44176

BIODATA PESERTA DIDIK

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

2. Tempat / Tgl. Lahir : ..........................................................................
3. Tempat Tinggal Calon : ..........................................................................
4. Pendidikan Terakhir Tahun : ..........................................................................
5. NISN : ..........................................................................
6. Agama : ..........................................................................
7. Nama Orang Tua : ..........................................................................
8. Tempat Tinggal : ..........................................................................
9. Pekerjaan Orang Tua : ..........................................................................
10. Agama : ..........................................................................
11. Nama Wali Calon : ..........................................................................
12. Pekerjaan Wali Calon : ..........................................................................
13. Alamat Calon : ..........................................................................

14. Sekolah Yang Dituju ; PILIHAN I : ..........................................................................

PILIHAN II : ..........................................................................

Cibalong, ................................... 2016

Mengetahui Calon Peserta Didik Baru

Orang Tua / Wali Calon

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