‫ُم َؤ َّس َس ُة الَّتْر ِب َّي ة ْاِإل ْس َال ِم َّي ِة اْلَعِش ْي َر ِة اْلَخ ْيِر َّية‬

YAYASAN PENDIDIKAN ISLAM

AL-ASYIROTUL KHAERIYAH
Sekretariat : Kp. Rawasaban Rt. 03/02 Ds. Suryabahari Kec. Pakuhaji Kab. Tangerang – Banten Kode Pos 15570

REKOMENDASI
(PENDAMPING WAJIB HADIR)
□ rekomendasi dari dalam lingkungan yayasan
FORMULIR PENDAFTARAN □ rekomendasi dari luar lingkungan yayasan
Nama :
TTD :
A. BIODATA PRIBADI
1. No. Pendaftaran : .......................................................................................................................
2. Nama Lengkap : .......................................................................................................................
3. NIS / NISN : .......................................................................................................................
a. Nomor Induk Siswa : .......................................................................................................................
b. NISN : .......................................................................................................................
4. Alamat : .......................................................................................................................
5. Tempat/Tanggal Lahir : .......................................................................................................................
6. Jenis Kelamin : Laki-laki Perempuan
7. Agama : .......................................................................................................................
B. ASAL SEKOLAH / MADRASAH
1. Status Terima : .......................................................................................................................
2. Tanggal STTB/Ijazah : .......................................................................................................................
3. Sekolah Asal : .......................................................................................................................
4. Alamat Sekolah : .......................................................................................................................
5. Nomor STTB/Ijazah : .......................................................................................................................

C. AKADEMIK
1. Jenjang Pendidikan yang ditempuh :
RA Madrasah Ibtidaiyah Madrasah Tsanawiyah Madrasah Aliyah Pondok Pesantren

D. ORANG TUA / WALI

1. Nama Ibu Kandung : .......................................................................................................................
a. Pendidikan : .......................................................................................................................
b. Pekerjaan : .......................................................................................................................
2. Nama Ayah Kandung : .......................................................................................................................
a. Pendidikan : .......................................................................................................................
b. Pekerjaan : .......................................................................................................................
3. Alamat : .......................................................................................................................
4. Wali : .......................................................................................................................
a. Nama wali : .......................................................................................................................
b. Pendidikan : .......................................................................................................................
c. Pekerjaan : .......................................................................................................................
d. Alamat : .......................................................................................................................
e. No. Telpon : .......................................................................................................................

PEMBERKASAN
Formulir Pendaftaran
Copy Ijazah Legalisir Asli
Copy Identitas/KTP
Pas Foto Pas Foto 3x4 (3Lembar/Terbaru)
NISN
3x4
Akta kelahiran dan KK
Fotocopy KIP (Jika Ada)

Suryabahari, .................................
Petugas pendaftaran Pendaftar

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