FORMULIR PENERIMAAN PESERTA DIDIK BARU (PPDB)

MADRASAH ALIYAH NURUL IMAN TAROWANG

TAHUN PELAJARAN 2022/2023
Alamat : Jl. Masjid Raya Tarowang Desa Tarowang Kec. Tarowang Kab. Jeneponto Kode Pos 92361
NPSN : 60729380 NSM : 131273040044

No.Pendaftaran
(Diisi oleh Panitia PPDB)

………………………..

A. KETERANGAN CALON PESERTA DIDIK

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

2. Jenis Kelamin : ....................................................................................................
3. Agama : …………………………………………………………………
4. NISN : …………………………………………………………………
5. NPSN : …………………………………………………………………
6. Asal Sekolah : …………………………………………………………………
7. NIK : ....................................................................................................
8. Tempat Lahir : ....................................................................................................
9. Tanggal Lahir : ....................................................................................................
10. Alamat Rumah : ....................................................................................................
11. Transportasi ke sekolah : ....................................................................................................
12. No. Hp/WA Calon Siswa Baru ( Wajib)* : ....................................................................................................

B. KETERANGAN ORANG TUA KANDUNG / WALI

1. Nama Lengkap/Wali
a. Ayah : ................................................................................................................................
b. Ibu : ................................................................................................................................
2. Tahun lahir/Wali
a. Ayah : ................................................................................................................................
b. Ibu : ................................................................................................................................
3. Pekerjaan/Wali
a. Ayah : ................................................................................................................................
b. Ibu : ................................................................................................................................
4. Alamat tempat tinggal : ................................................................................................................................
………………………………………………………………................................

C. LAMPIRAN YANG DISERAHKAN BERSAMA FORMULIR PENDAFTARAN

1. Pas foto 3 x 4 : 3 lembar latar merah
2. Fc.Kartu keluarga(KK) : 1 lembar
3. Fc.Ktp Orang Tua : 1 lembar
4. Fc.Ijasah SD : 1 lembar
5. Fc. Akte Kelahiran : 1 Lembar
6. Kps/KKS/KIP Dll (jika ada) : 1 lembar

Tarowang, 2022
Diketahui oleh,
Orang Tua/Wali Peserta Didik Calon Peserta Didik

3x4
( Warna )
................................................ ................................

Catatan :
1. Formulir Pendaftaran di Tulis dengan huruf Balok atau Huruf Besar
2. Formulir dikembalikan paling lambat tiga hari setelah pengambilan
Formulir.
 No.Pendaftaran
(MA. Nurul Iman Tarowang)
Pas Foto
3x4
………………………..

Paraf Panitia …………

KARTU PENDAFTARAN CALON PESERTA DIDIK
1. Nama Lengkap : .....................................................................................................
2. Jenis Kelamin : .....................................................................................................
3. Agama : ………………………………………………………………….
4. NISN : ………………………………………………………………….
5. NPSN : ………………………………………………………………….
6. Asal Sekolah : ………………………………………………………………….
7. NIK : .....................................................................................................
8. Tempat Lahir : .....................................................................................................
9. Tanggal Lahir : .....................................................................................................
10. Alamat Rumah : .....................................................................................................
11. Transportasi ke sekolah : .....................................................................................................
12. No.Hp Calon Siswa Baru : .....................................................................................................

------------------------------------------------------------------------------------------------------------------------------------------

No.Pendaftaran
(MA. Nurul Iman Tarowang)
Pas Foto
3x4
………………………..

Paraf Panitia …………

KARTU PENDAFTARAN CALON PESERTA DIDIK
1. Nama Lengkap : .....................................................................................................
2. Jenis Kelamin : .....................................................................................................
3. Agama : ………………………………………………………………….
4. NISN : ………………………………………………………………….
5. NPSN : ………………………………………………………………….
6. Asal Sekolah : ………………………………………………………………….
7. NIK : .....................................................................................................
8. Tempat Lahir : .....................................................................................................
9. Tanggal Lahir : .....................................................................................................
10. Alamat Rumah : .....................................................................................................
11. Transportasi ke sekolah : .....................................................................................................
12. No.Hp Calon Siswa Baru : .....................................................................................................

------------------------------------------------------------------------------------------------------------------------------------------

No.Pendaftaran
(MA. Nurul Iman Tarowang)
Pas Foto
3x4 ………………………..

Paraf Panitia …………

KARTU PENDAFTARAN CALON PESERTA DIDIK
1. Nama Lengkap : .....................................................................................................
2. Jenis Kelamin : .....................................................................................................
3. Agama : ………………………………………………………………….
4. NISN : ………………………………………………………………….
5. NPSN : ………………………………………………………………….
6. Asal Sekolah : ………………………………………………………………….
7. NIK : .....................................................................................................
8. Tempat Lahir : .....................................................................................................
9. Tanggal Lahir : .....................................................................................................
10. Alamat Rumah : .....................................................................................................
11. Transportasi ke sekolah : .....................................................................................................
12. No.Hp Calon Siswa Baru : .....................................................................................................