PKBM KUNTUM MELATI

No.Ijin Operasional : 421.10/081/00006/DMPPTSP/2022

Telp. (0251) 8254621 / WA 082299508870

FORMULIR PESERTA DIDIK

Daftar Tingkat □ Paket A/Setara SD □ Paket B/Setara SMP □ Paket C/Setara SMA

DATA PRIBADI

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

2. Jenis Kelamin : Laki-laki / Perempuan
3. NISN (jika memiliki) : ...........................................................................................
4. Tempat/Tgl Lahir : ...........................................................................................
5. No. KK : ...........................................................................................
6. NIK : ...........................................................................................
7. No.Registrasi Akta Lahir : ...........................................................................................
8. Agama : ...........................................................................................
9. Status : Menikah / Belum menikah
10. Pekerjaan : ...........................................................................................
11. Alamat
a. Jalan : ...........................................................................................
b. RT / RW : ...........................................................................................
c. Nama Dusun : ...........................................................................................
d. Kelurahan/Desa : ...........................................................................................
e. Kecamatan : ...........................................................................................
f. Kabupaten/Kota : ...........................................................................................
g. Kode Pos : ...........................................................................................
h. Lintang : ...........................................................................................
i. Bujur : ...........................................................................................
12. Nomor HP : ...........................................................................................
13. Anak keberapa : ...........................................................................................
14. Jumlah Saudara Kandung : ...........................................................................................
15. Apakah punya KIP : Ya / Tidak
16. Tinggi Badan : ................. cm
17. Berat Badan : ................. kg
18. Lingkar Kepala : ................. cm

DATA ORANG TUA / WALI

Data Ayah Kandung

1. Nama Ayah Kandung : ...........................................................................................
2. NIK : ...........................................................................................
3. Tempat/Tgl Lahir : ...........................................................................................
4. Pendidikan Tertinggi : ...........................................................................................
5. Pekerjaan : ...........................................................................................
Data Ibu Kandung
1. Nama Ibu Kandung : ...........................................................................................
2. NIK : ...........................................................................................
3. Tempat/Tgl Lahir : ...........................................................................................
4. Pendidikan Tertinggi : ...........................................................................................
5. Pekerjaan : ...........................................................................................

Data Wali
1. Nama Ayah Kandung : ...........................................................................................
2. NIK : ...........................................................................................
3. Tempat/Tgl Lahir : ...........................................................................................
4. Pendidikan Tertinggi : ...........................................................................................
5. Pekerjaan : ...........................................................................................

......................., .............................. 20....

Pendaftar

Persyaratan :

1. Fotokopi Ijazah Terakhir : 2 Lembar

2. Fotokopi Kartu Keluarga : 2 Lembar
3. Fotokopi Akta Kelahiran : 2 Lembar
4. Fotokopi KTP Ayah & Ibu / Wali : 2 Lembar
5. Fotokopi KTP pendaftar (17+) : 2 lembar
6. Photo Ukuran 2x3 dan 3 x 4 : 2 Lembar