Nama : ...........................................................................................................
Alamat : ...........................................................................................................
Pekerjaan : ...........................................................................................................
Dengan ini mengajukan permohonan pindah masuk anak/adik kami :
Nama : ...........................................................................................................
Tempat/Tanggal Lahir : ...........................................................................................................
Jenis Kelamin : ...........................................................................................................
Kelas : ...........................................................................................................
NISN : ...........................................................................................................
Asal Madrasah/Sekolah : ...........................................................................................................
Kami mohon dengan hormat agar anak/adik kami dapat diterima di Madrasah Aliyah
Negeri Kota Kupang.
Demikian permohonan kami sampaikan atas perkenaan bapak kami haturkan limpah
terima kasih.
Kupang, ……………………….........
Pemohon,
.......................................................