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YAYASAN PENDIDIKAN ISLAM

MADRASAH ALIYAH AL FALAAH BANJAR BARU


NSM : 131218050003 NPSN : 10816372
AKREDITASI : B
Jl.Rawa Pitu Kampung Mekar Indah Jaya, RT 002/RW 003 Kec. Banjar Baru Kab. Tulang bawang

FORMULIR PENDAFTARAN SISWA BARU


Nomer Pendaftaran: ................................................................

A. IDENTITAS SISWA
1. Nama Lengkap Sesuai Ijazah :.............................................................
2. Jenis kelamin : ............................................................
3. Tempat dan tanggal lahir :..............................................................
4. Agama :.............................................................
5. Alamat sekarang :.............................................................
6. Sekolah Asal
a. Nama Sekolah :................................................................
b. Alamat Sekolah :................................................................
7. Nomer NISN :................................................................
8. Nomer peserta Ujian :...............................................................
9. Nomer Ijazah :...............................................................
B. IDENTITAS ORANG TUA (AYAH)
1. Nama Ayah :.............................................................
2. Tempat Tanggal lahir :.............................................................
3. Agama :............................................................
4. Pekerjaan Ayah :.............................................................
5. Alamat Rumah :..............................................................
C. IDENTITAS ORANG TUA (IBU)
1. Nama Ibu :.............................................................
2. Tempat Tanggal lahir :.............................................................
3. Agama :..............................................................
4. Pekerjaan Ibu :...............................................................
5. Alamat Rumah :.............................................................
D. ADMINISTRASI PENDAFTARAN : 50.000

Banjar Baru,................................2021
Orang Tua/Wali, Calon Siswa,

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Panitia PSB,

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