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PEMERINTAH KABUPATEN BOYOLALI

KOORDINATOR PAUD DIKDAS DAN LS


KECAMATAN ANDONG
SEKOLAH DASAR NEGERI 2 BANARAN
Alamat : Ngembat, Sempu, Andong, Boyolali, Kode Pos 57384

IDENTITAS PESERTA DIDIK

1. Nama : ...................................................................................................
2. NIS : ...................................................................................................
3. NISN : ...................................................................................................
4. Tempat Tanggal Lahir : ...................................................................................................

5. Jenis Kelamin : ...................................................................................................


6. Pendidikan Sebelumnya : ...................................................................................................
7. Anak Nomer : ...................................................................................................
8. Jumlah Saudara : ...................................................................................................
9. Alamat Peserta Didik : ...................................................................................................

10. Nama Orang Tua : ...................................................................................................


a. Ayah : ...................................................................................................
b. Ibu : ...................................................................................................
11. Pekerjaan Orang Tua : ...................................................................................................
a. Ayah : ...................................................................................................
b. Ibu : ...................................................................................................
12. Alamat Orang Tua : ...................................................................................................
a. Jalan : ...................................................................................................
b. Kelurahan : ...................................................................................................
c. Kecamatan : ...................................................................................................
d. Kabupaten : ...................................................................................................
e. Provinsi : ...................................................................................................
13. Wali Peserta Didik : ...................................................................................................
a. Nama : ...................................................................................................
b. Pekerjaan : ...................................................................................................
c. Alamat : ...................................................................................................

Banaran, Juli 2023


Mengetahui
Kepala Sekolah
SITI NURCHAYATI, S.Pd
NIP. 19710205 200701 2 017

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