Nama Madrasah :MTs Nurul Falah Tanah Wulan Mata Pelajaran :......................................
Nama Guru :............................................. Sertifikasi :.........................................
Jabatan Lain :………………………………………….
Predikat Nilai
Amat Baik (AB) 90 -100
Baik ( B) 75- 89
Cukup (C) 60-74
Kurang (K) < 60
Catatan:.....................................................................................................................................................
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Tindak lanjut : ..................................................................................................................................
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Bondowoso,
Kepala Madrasah. Guru yang dinilai,
Agus Junaidi,S.Pd
Nip.