BIODATA SISWA

PEMERINTAH DAERAH PROVINSI JAWA BARAT

DINAS PENDIDIKAN
CABANG DINAS PENDIDIKAN WILAYAH VII
SMK NEGERI 13 BANDUNG
Jl Soekarno Hatta Km 10 Telp/ Fax 022-7318960 Bandung 40286

Nama siswa : ....................................................................................................

NIS/NISN : ....................................................................................................
Tempat, Tgl.lahir : ....................................................................................................
Jenis Kelamin : ....................................................................................................
Agama : ....................................................................................................
No. telp/Hp siswa : ....................................................................................................
Golongan Darah : ..................... Rhesus : ....................................................
Tinggi/Berat Badan : ..................... cm/ ..................... kg
Warna Kulit : ....................................................................................................
Mata* : Normal/Plus/Minus/Silindris*. Keterangan: …..…………...
Penyakit berat yang pernah diderita :
………………........... Tahun : …………… ket : ……………………………………………..
………………........... Tahun : …………… ket : ……………………………………………..
Alergi terhadap : ....................................................................................................
Nama Orang Tua/Wali : ....................................................................................................
Alamat Orang Tua/Wali : ....................................................................................................
....................................................................................................
No. Tlp. Orang Tua/Wali : ....................................................................................................
Selama mengikuti Prakerin tinggal di: Rumah sendiri/Kost/Rumah saudara/Asrama/Lain-
lain* keterangan : .................................................................................................... Alamat :
.................................................................................................... No. Telp. :
....................................................................................................
Dengan ini menyatakan bahwa data diatas dibuat dengan sebenar-benarnya.

Bandung, ………………. 2022

Yang bersangkutan,

(………………………………)

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 IDENTITAS INDUSTRI/INSTANSI

Perusahaan/Institusi
Nama :...............................................
...............................................
Alamat : ...............................................
...............................................
...............................................

Bidang Produk/Jasa : ...............................................

Status : PMA/PMDN/BUMN/Negeri *

Nomor Telp : ...............................................

Nomor Fax : ...............................................
E-mail : ...............................................
Website : ...............................................

Pimpinan
Jabatan : Direktur/Kepala/Lainnya *.........
Nama : ...............................................

HRD/Ka.TU
Nama : ...............................................
No. Telp –Ext : ...............................................
E-mail : ...............................................

Pembimbing
Jabatan : ...............................................
Nama : ...............................................
No. Telp –Ext : ...............................................
E-mail : ...............................................

Keterangan : (*) coret yang tidak perlu

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