PEMERINTAH KABUPATEN SUKAMARA

DINAS PENDIDIKAN DAN KEBUDAYAAN

SMP NEGERI 2 BALAI RIAM
Jalan Air Dua Desa Sekuningan Baru RT 12 RW 03 Kecamatan Balai Riam 74773

FORMULIR PENERIMAAN PESERTA DIDIK BARU TAHUN PELAJARAN 2022/2023

A. KETERANGAN CALON PESERTA DIDIK

1. Nama Lengkap : ......................................................................
2. Jenis Kelamin : ...................................................................... Pas
3. NIK : ...................................................................... Photo
4. Tempat, Tanggal Lahir : ...................................................................... 3x4
5. Agama : ......................................................................
6. Alamat : ......................................................................
Desa : ......................................................................
Kecamatan : ............................................................................................................
.
Kabupaten : ............................................................................................................
.
Provinsi : ............................................................................................................
.
7. Alat Transportasi
: ............................................................................................................
.
8. Nomor HP
: ............................................................................................................
.
9. Asal Sekolah SD/MI
: ............................................................................................................
.
10. NISN : ............................................................................................................
.
11. Tahun Lulus
: ............................................................................................................
.
12. Email Aktif
: ............................................................................................................
.

B. KETERANGAN ORANG TUA / WALI

1. Nama Lengkap
a. Ayah : ............................................................................................................................
b. Ibu : ............................................................................................................................
2. Tahun Lahir
a. Ayah : ............................................................................................................................
b. Ibu : ............................................................................................................................
3. Pendidikan Terakhir
a. Ayah : ............................................................................................................................
b. Ibu : ............................................................................................................................
4. Pekerjaan
a. Ayah : ............................................................................................................................
b. Ibu : ............................................................................................................................
5. Penghasilan Rata-rata Perbulan (Rp)
a. Ayah : (0–999.999), (1.000.000– 1.999.999), (2.000.000–4.999.999), (5 Juta
Keatas)*
b. Ibu : (0–999.999), (1.000.000– 1.999.999), (2.000.000–4.999.999), (5 Juta
Keatas)*

C. DATA PERIODIK CALON PESERTA DIDIK

1. Tinggi Badan / Berat Badan : ............. cm / .............. kg
2. Jarak Rumah ke Sekolah : ............. km
D. PRESTASI YANG PERNAH DIRAIH SELAMA BERSEKOLAH
1. Jenis Prestasi : ................................................................................(jika
memiliki)
2. Peringkat / Juara : ................................................................................(jika
memiliki)
3. Katagori / Jenis Lomba : ................................................................................(jika
memiliki)

Balai Riam, …………………………

2021

Orang Tua / Wali Peserta Didik Calon Peserta Didik

(...................................................) (.................................................)

Keterangan :
*) Coret yang tidak perlu