FORMULIR PENDAFTARAN PIP

(PELAJAR INDONESIA PINTAR)

LELY PURWANDARI
KOMANDANTE

NAMA SISWA : .......................................................................................................

KELAS : ................................. NISN : ............................................................

Tempat, Tanggal Lahir : .......................................................................................................

ALAMAT : .......................................................................................................
KELURAHAN : ................................. KECAMATAN : ...............................................
KOTA : ................................. PROPINSI : .....................................................

NAMA SEKOLAH : .......................................................................................................

NPSN : .......................................................................................................
ALAMAT SEKOLAH : .......................................................................................................

KELURAHAN : ................................. KECAMATAN : ...............................................

NAMA AYAH : .......................................................................................................

No. HP : .......................................................................................................

NAMA IBU : .......................................................................................................

No. HP
NO. KARTU KELUARGA: .......................................................................................................

*) Lampirkan :
1. FC. KTP Suami/Istri
2. FC. Kartu Keluarga
3. FC. AKTA Anak
4. Nomor HP Wajib Aktif