KEMENTERIAN AGAMA REPUBLIK INDONESIA

KANTOR KEMENTERIAN AGAMA KABUPATEN KUTAI BARAT

MADRASAH TSANAWIYAH NEGERI KUTAI BARAT
Jalan Islamic Center I RT.32 Melak Kutai Barat Kalimantan Timur
Website.www.mtsnegerimelak.weebly.com

FORMULIR PENDAFTARAN CALON PESERTA DIDIK BARU

MADRASAH TSANAWIYAH NEGERI KUTAI BARAT
TAHUN PELAJARAN 2020/2021

A. KETERANGAN TENTANG DIRI SISWA

1. Nama Siswa

a. Nama lengkap :…………………………………………………………..

b. Nama panggilan :…………………………………………………………..
2. Jenis kelamin :…………………………………………………………..
3. Tempat tanggal lahir :…………………………………………………………..
4. Agama :…………………………………………………………..
5. NIS NASIONAL :…………………………………………………………..
6. NIK ( SISWA ) :…………………………………………………………..
7. NIK ( Kartu Keluarga ) :…………………………………………………………..
8. Alamat lengkap : Jln ………………………………………………...........
……………………………………………………………
...................................................................................
9. Telepon / handpone :…………………………………………………………..
10. Warga Negara :…………………………………………………………..
11. Madrasah/Sekolah asal

a. Nama madrasah :…………………………………………………………..

/sekolah
b. Alamat :…………………………………………………………..
c. Nomor Pokok Sekolah : …………………………………………………………..
Nasional
12. Status dalam keluarga :…………………………………………………………..
13. Anak ke :………… dari ……… saudara
14. Jumlah saudara

a. Kandung :………………orang
b. Tiri :………………orang
15. Bahasa sehari-hari di rumah :…………………………………………………………..
16. Golongan darah :…………………………………………………………..
17. Tinggi badan :………………………. Berat badan …………………….
18. Prestasi yang pernah di :…………………………………………………………..
Raih
19. Hoby :…………………………………………………………..

 WAJIB DI ISI SEMUA DARI NO. 1 S/D 17

B. KETERANGAN ORANG TUA / WALI PESERTA DIDIK :

I. AYAH

1. NAMA : ...............................................................................................
2. NIK : ...............................................................................................
3. TEMPAT TANGGAL LAHIR : ...............................................................................................
4. AGAMA : ...............................................................................................
5. PENDIDIKAN TERAKHIR : ...............................................................................................
6. PEKERJAAN : ...............................................................................................
7. PENGHASILAN PERBULAN : ...............................................................................................
8. NO TELPON/ HP : ...............................................................................................
9. ALAMAT SEKARANG : ...............................................................................................
...............................................................................................
...............................................................................................

II. IBU

1. NAMA : .............................................................................................
..
2. NIK : .............................................................................................
..
3. TEMPAT TANGGAL LAHIR
: ...............................................................................................
4. AGAMA : .............................................................................................
..
5. PENDIDIKAN TERAKHIR : ...............................................................................................
6. PEKERJAAN : ...............................................................................................
7. PENGHASILAN PERBULAN : ...............................................................................................
8. NO TELPON/ HP : ...............................................................................................
9. ALAMAT SEKARANG : ...............................................................................................
...............................................................................................
...............................................................................................

III. WALI

1. NAMA : ...............................................................................................
2. NIK : ...............................................................................................
3. TEMPAT TANGGAL LAHIR : ...............................................................................................
4. AGAMA : ...............................................................................................
5. PENDIDIKAN TERAKHIR : ...............................................................................................
6. PEKERJAAN : ...............................................................................................
7. PENGHASILAN PERBULAN : ...............................................................................................
8. NO TELPON/ HP : ...............................................................................................
9. ALAMAT SEKARANG : ...............................................................................................
...............................................................................................
...............................................................................................