PEMERINTAH DAERAH PROVINSI JAWA BARAT

DINAS PENDIDIKAN
Jalan Dr. Radjiman No. 6 Telp. (022) 4264813 Fax. (022) 4264881
Wisselbord (022) 4264944, 4264957, 4264973
BANDUNG (40171)

BIODATA PESERTA
LKS SMK TINGKAT PROVINSI JAWA BARAT
TAHUN 2018

KABUPATEN/KOTA : ....................................................
BIDANG LOMBA : ....................................................

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

2. NIS / NISN : ..................................................................................
3. Tempat/Tanggal Lahir : ..................................................................................
4. Jenis Kelamin : Laki-laki/Perempuan*)
5. Agama : ..................................................................................
6. Program Studi Keahlian : ..................................................................................
7. Kelas : ..................................................................................
8. Asal Sekolah : ..................................................................................
9. Alamat Sekolah : ..................................................................................
..................................................................................
Kab./Kota*) .........................................
10. Alamat Rumah : ..................................................................................
Desa/Kel*) ................................................................
Pas Photo Kecamatan ...............................................................
(Berwarna)
No. Tlp. (......) ...................... HP. .............................
E-mail : .................................................................
3x4

Mengetahui : .................................., .....................

Kepala SMK ................................................. 2018
.....................................................................
Peserta,

( .................................................................)
PEMERINTAH DAERAH PROVINSI JAWA BARAT
NIP. ....................................................... ( ....................................................)

Catatan : - Diisi dengan huruf kapital

DINAS PENDIDIKAN
- *) coret yang tidak perlu
Jalan Dr. Radjiman No. 6 Telp. (022) 4264813 Fax. (022) 4264881
Wisselbord (022) 4264944, 4264957, 4264973
BANDUNG (40171)
 BIODATA PEMBIMBING
LKS SMK TINGKAT PROVINSI JAWA BARAT
TAHUN 2018

KABUPATEN/KOTA : ....................................................
BIDANG LOMBA : ....................................................

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

2. NIP /NUPTK : ..................................................................................
3. Pangkat/Gol. : ..................................................................................
4. Tempat/Tanggal Lahir : ..................................................................................
5. Jenis Kelamin : Laki-laki/Perempuan*)
6. Agama : ..................................................................................
7. Asal Sekolah : ..................................................................................
8. Alamat Sekolah : ..................................................................................
..................................................................................
Kab./Kota*) .........................................
9. Alamat Rumah : ..................................................................................
Desa/Kel*) ................................................................
Pas Photo Kecamatan ...............................................................
(Berwarna)
No. Tlp. (......) ...................... HP. .............................
E-mail : .................................................................
3x4

Mengetahui : .................................., .....................

Kepala SMK ................................................. 2018
.....................................................................
Pembimbing,

( .................................................................)
NIP. ....................................................... ( ....................................................)

Catatan : - Diisi dengan huruf kapital

- *) coret yang tidak perlu