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NO.

PENDAFTARAN
2021006900000 FORMULIR
PENDAFTARAN ULANG
SMP N 3 KOTA SOLOK
TAHUN PELAJARAN 2021/2022

DATA SISWA
NAMA LENGKAP : RUCI FAUZIA
TEMPAT, TGL LAHIR : SOLOK, 23 NOVEMBER 2008
JENIS KELAMIN : PEREMPUAN
AGAMA : ISLAM
ASAL SEKOLAH : SDN 19 KAMPUNG JAWA

DATA ORANG TUA/WALI


NAMA AYAH : SUHERMAN
TEMPAT, TGL LAHIR : .....................................................................................................................
AGAMA : .....................................................................................................................
PENDIDIKAN : .....................................................................................................................
PEKERJAAN : .....................................................................................................................
ALAMAT : .....................................................................................................................
.....................................................................................................................
TELEPON : .....................................................................................................................

NAMA IBU : MAWARNI


TEMPAT, TGL LAHIR : .....................................................................................................................
AGAMA : .....................................................................................................................
PENDIDIKAN : .....................................................................................................................
PEKERJAAN : .....................................................................................................................
ALAMAT : .....................................................................................................................
.....................................................................................................................
TELEPON : .....................................................................................................................

NAMA WALI : .....................................................................................................................


TEMPAT, TGL LAHIR : .....................................................................................................................
AGAMA : .....................................................................................................................
PENDIDIKAN : .....................................................................................................................
PEKERJAAN : .....................................................................................................................
ALAMAT : .....................................................................................................................
.....................................................................................................................
TELEPON : .....................................................................................................................
HUBUNGAN DENGAN SISWA : .....................................................................................................................

DEMIKIAN FORMULIR INI SAYA ISIKAN DENGAN SEBENAR-BENARNYA AGAR DAPAT DIGUNAKAN
SEBAGAIMANA MESTINYA. APABILA DIKEMUDIAN HARI TERBUKTI DATA YANG SAYA ISIKAN
SALAH/TIDAK BENAR MAKA SAYA BERSEDIA MENERIMA SANKSI SESUAI ATURAN YANG
BERLAKU.

Orang tua/wali

(.................................................)

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