PANITIA PENERIAAN PESERTA DIDIK BARU ( PPDB )

SMA AL-MUKHTARIYAH RAJAMANDALA

TAHUN PELAJARAN 2022/2023

Jl.Statsion Rajamandala No. 01 Ds. Mandalasari Kec.Cipatat Kab. Bandung Barat 40754

Tlp. 08382134866 / 085778104630 / 085795336057

NOMOR )**
FORMULIR PENDAFTARAN

DATA PESERTA DIDIK :

NAMA : ............................................................................................................................
NISN : ............................................................................................................................
JENIS KELAMIN : LAKI – LAKI / PEREMPUAN )*
TEMPAT, TANGGAL LAHIR : ............................................................................................................................
ANAK KE : ......................DARI....................SAUDARA
ALAMAT SISWA : ....................................................................RT..........RW...................................
DS.........................................................KEC.........................................................
KAB/KOTA :..........................................................................................................
DATA PENDIDIKAN
ASAL SEKOLAH SMP/MTs : ............................................................................................................................
ALAMAT SEKOLAH : ............................................................................................................................
TAHUN LULUS : ............................................................................................................................

JURUSAN YANG DIMINATI )* : IPA IPS

DATA KELUARGA
TINGGAL DENGAN : ORANG TUA / WALI )*
NAMA AYAH : ............................................................................................................................
PEKERJAAN AYAH : ............................................................................................................................
NAMA IBU : ............................................................................................................................
PEKERJAAN IBU : ............................................................................................................................
ALAMAT ORANG TUA : .....................................................................RT..........RW............ .....................
DS.........................................................KEC................................... .....................
KAB/KOTA :..................................................................................... ....................

NO.TELEPON / HP/WA Aktif : ............................................................................................................................

DATA WALI ( jika dengan wali )

NAMA WALI : ............................................................................................................................
ALAMAT WALI : .....................................................................RT..........RW............ .....................
DS.........................................................KEC................................... .....................
KAB/KOTA :..................................................................................... ....................
.KELENGKAPAN :
NO BERKAS-BERKAS YANG HARUS DI BAWA KETIKA DAFTAR ULANG ADA TIDAK
1 SURAT KETERANGAN LULUS SEKOLAH ASLI
2 FC. IJAZAH SMP/MTs 2 LEMBAR ( BILA SUDAH KELUAR )    
3 FC. IJAZAH SD/MI 2 LEMBAR    
4 FC. AKTE KELAHIRAN 2 LEMBAR    
5 FC. KARTU KELUARGA 2 LEMABAR    
6 FC. KTP ORANG TUA 2 LEMBAR    
7 FC. KIP/KPS/KKS/PKH ( BILA PUNYA )    
8 TAMBAHAN BAGI PINDAHAN :    
SURAT PINDAH ASLI    
SURAT MUTASI DARI DAPODIK    
RAPORT ASLI    

TINGGAL DI ASRAMA/PASANTREN : YA Nama Pesantren............................................../ TIDAK )*

ORANG TUA / WALI CIPATAT.......,............................2023

 PANITIA PENERIAAN PESERTA DIDIK BARU ( PPDB )
SMA AL-MUKHTARIYAH RAJAMANDALA
TAHUN PELAJARAN 2022/2023

Jl.Statsion Rajamandala No. 01 Ds. Mandalasari Kec.Cipatat Kab. Bandung Barat 40754

Tlp. 08382134866 / 085778104630 / 085795336057

PESERTA DIDIK

............................................. .............................................
Ket: )** Diisi oleh petugas
)* Coret yang tidak pelu