PEMERINTAH PROVINSI JAWA TIMUR

DINAS PENDIDIKAN
CABANG DINAS PENDIDIKAN WILAYAH TULUNGAGUNG
SEKOLAH MENENGAH KEJURUAN NEGERI 2 BOYOLANGU
Jalan Ki Mangunsarkoro VI/1 Tel/Fax. (0355) 322989/ 335125 web-site:www.smkn2boyolanu.sch.id
e-mail: smkn2boyolangu@gmail.com
TULUNGAGUNG
Kode Pos: 66233

DAFTAR ULANG KELAS X Program Keahlian : _____________________________

TAHUN PELAJARAN 2023/2024 NISN : _____________________________

A. KETERANGAN TENTANG PESERTA DIDIK

01. Nama Lengkap : ............................................................................................
Nama Panggilan : ............................................................................................
02. Jenis Kelamin : ............................................................................................
03. Tempat dan Tanggal Lahir : ............................................................................................
04. Agama : ............................................................................................
05. Kewarganegaraan : ............................................................................................
06. Anak ke-berapa : ............................................................................................
07. Jumlah Saudara Kandung : ............................................................................................
08. Jumlah Saudara Tiri : ............................................................................................
09. Jumlah Saudara Angkat : ............................................................................................
10. Anak Yatim/Piatu/Yatim Piatu : ............................................................................................
11. Bahasa sehari-hari di rumah : ............................................................................................

B. KETERANGAN TEMPAT TINGGAL

12. Alamat lengkap : Jalan ..................................................................................
RT/RW............................. Dusun.......................................
Desa............................................ Kec................................
Kab. ....................................... Kode Pos ...........................
13. Nomor telepon/HP : ............................................................................................
14. Tinggal dengan : orangtua saudara asrama kost
15. Jarak tempat tinggal ke sekolah : ............................................................................................

C. KETERANGAN KESEHATAN
16. Golongan darah : ............................................................................................
17. Penyakit yang pernah diderita : ............................................................................................
18. Kelainan jasmani : ............................................................................................
19. Tinggi dan berat badan saat diterima disekolah ini : ................. cm ...................... kg
20. Tidak buta Warna : Ya Tidak

D. KETERANGAN PENDIDIKAN
21. Pendidikan sebelumnya
a. Tamatan dari sekolah : ............................................................................................
b. Nomor Ijazah dan Tanggal : ............................................................................................
c. Nomor SHUN dan tanggal : ............................................................................................
d. Lama Belajar : ............................................................................................
e. NISN : ............................................................................................
22. Diterima di sekolah ini
a. Kelas : ............................................................................................
b. Program Keahlian : Akuntansi dan Keuangan Lembaga
Perhotelan
Kuliner
Kecantikan dan Spa
Busana
c. Tanggal / Bulan / Tahun : ............................................................................................

E. KETERANGAN TENTANG AYAH KANDUNG PESERTA DIDIK

23. Nama Lengkap : ............................................................................................
24. Tempat dan Tanggal Lahir : ............................................................................................
25. Agama : ............................................................................................
SIS word Daftar ulang siswa
 26. Kewarganegaraan : ............................................................................................
27. Pendidikan : ............................................................................................
28. Pekerjaan : ............................................................................................
29. Pengeluaran tiap bulan : ............................................................................................
30. Alamat lengkap : Jalan ..................................................................................
RT/RW............................. Dusun.......................................
Desa............................................ Kec................................
Kab. ....................................... Kode Pos ...........................
31. Nomor telepon/HP : ............................................................................................
32. Masih Hidup/Meninggal : ............................................................................................
F. KETERANGAN TENTANG IBU KANDUNG PESERTA DIDIK
33. Nama Lengkap : ............................................................................................
34. Tempat dan Tanggal Lahir : ............................................................................................
35. Agama : ............................................................................................
36. Kewarganegaraan : ............................................................................................
37. Pendidikan : ............................................................................................
38. Pekerjaan : ............................................................................................
39. Pengeluaran tiap bulan : ............................................................................................
40. Alamat lengkap : Jalan ..................................................................................
RT/RW............................. Dusun.......................................
Desa............................................ Kec................................
Kab. ....................................... Kode Pos ...........................
41. Nomor telepon/HP : ............................................................................................
42. Masih Hidup/Meninggal : ............................................................................................
G. KETERANGAN TENTANG WALI PESERTA DIDIK
43. Nama Lengkap : ............................................................................................
44. Tempat dan Tanggal Lahir : ............................................................................................
45. Agama : ............................................................................................
46. Kewarganegaraan : ............................................................................................
47. Pendidikan : ............................................................................................
48. Pekerjaan : ............................................................................................
49. Pengeluaran tiap bulan : ............................................................................................
50. Alamat lengkap : Jalan ..................................................................................
RT/RW............................. Dusun.......................................
Desa............................................ Kec................................
Kab. ....................................... Kode Pos ...........................
51. Nomor telepon/HP : ............................................................................................
52. Masih Hidup/Meninggal : ............................................................................................
H. KEGEMARAN PESERTA DIDIK
53. Kesenian : ............................................................................................
54. Olahraga : ............................................................................................
55. Kemasyarakatan/Organisasi : ............................................................................................
56. Lain-lain : ............................................................................................
Demikian formulir pendapatan ini saya buat dengan sebenar-benarnya dan penuh tanggung
jawab untuk dipergunakan sebagaimana mestinya.

Tulungagung, 2023
Mengetahui, Yang Membuat,
Orangtua/Wali PDB

______________________ _______________________

Catatan:
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SIS word Daftar ulang siswa