A. IDENTITAS SISWA :
1. Nama Lengkap Siswa :........................................................
2. Jenis Kelamen :........................................................
3. Tempat Dan Tanggal Lahir :.......................................................
4. Agama :.......................................................
5. Alamat Sekarang :.......................................................
6. Sekolah Asal :.......................................................
a. Nama Sekolah :.......................................................
b. Alamal Sekolah :.......................................................
7. Nomor Peserta Berdasarkan NISN :.......................................................
8. Nomor Peserta Ujian SD :.......................................................
9. Nomor STTB/Tahun Lulus :.......................................................
10.Nomor SKHUN :.......................................................
11.Jumlah Nilai STTB Rata-Rata :.......................................................
B. IDENTITAS ORANG TUA (AYAH) :......................................................
1. Nama Ayah :.......................................................
2. Tempat dan Tanggal Lahir :......................................................
3. Agama :......................................................
4. Pekerjaan :......................................................
5. Alamat Sekarang :......................................................
C. IDENTITAS ORANG TUA (IBU) :......................................................
1. Nama Ibu :......................................................
2. Tempat Dan Tanggal Lahir :......................................................
3. Agama :......................................................
4. Pekerjaan :......................................................
5. Alamat Sekarang :......................................................
Pamekasan.............................2021
Panitia PSBB Calon Siswa Baru
Foto Siswa
3x4
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