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,
................................................ .....................................
Panitia PSB,
.........................