YAYASAN PONDOK PESANTREN MIFTAHUL ULUM

PANITIA PENERIMAAN PESERTA DIDIK BARU (PPDB)

SMK IBRAHIMY
TAHUN PELAJARAN 2023/2024
Alamat : Jl. Raya Situbondo No.102 Bengkak Wongsorejo Banyuwangi Website : www.mifulbengkak.net

FORMULIR PENDAFTARAN SISWA BARU NOMOR

PENDAFTARAN

TAHUN PELAJARAN 2023/2024

………………
A. KETERANGAN PRIBADI
1. Nama : ....................................................................................................................................
2. Jenis Kelamin : ....................................................................................................................................
3. Tempat/ Tanggal Lahir : ....................................................................................................................................
4. Golongan darah : ....................................................................................................................................
5. Agama : ....................................................................................................................................
6. Alamat Sekarang : a. Asrama :................................................................................................................
b. Rumah :................................................................................................................
7. No. Telepon/HP : ....................................................................................................................................
8. Jumlah saudara kandung/tiri : ....................................................................................................................................

B. PENDIDIKAN
1. Sekolah Asal : ....................................................................................................................................
2. Ijazah Terakhir : ....................................................................................................................................
3. Tanggal/ No. STK : ....................................................................................................................................
4. Alamat Sekolah : ....................................................................................................................................
5. Lama Belajar : ....................................................................................................................................
C. ORANG TUA
1. AYAH
a. Nama : ....................................................................................................................................
b. Tempat, Tanggal Lahir : ....................................................................................................................................
c. Alamat : ....................................................................................................................................
d. Pekerjaan : ....................................................................................................................................
e. Pendidikan Terahir : ....................................................................................................................................
2. IBU
a. Nama : ....................................................................................................................................
b. Tempat, Tanggal Lahir : ....................................................................................................................................
c. Alamat : ....................................................................................................................................
d. Pekerjaan : ....................................................................................................................................
e. Pendidikan Terahir : ....................................................................................................................................
3. WALI SISWA
a. Nama : ....................................................................................................................................
b. Tempat, Tanggal Lahir : ....................................................................................................................................
c. Alamat : ....................................................................................................................................
d. Pekerjaan : ....................................................................................................................................
e. Pendidikan Terahir : ....................................................................................................................................
f. No. Telephone/Hp : ....................................................................................................................................

D. PILIHAN JURUSAN KHUSUS SISWA SMK

MULTIMEDIA

E. SYARAT-SYARAT DAN YANG DILAMPIRKAN

No Syarat-syarat Banyak Ada Tidak Ada

1. Foto copy Ijazah / Surat Keterangan Kelulusan ( SKL ) 1 Lembar
2. Pas Photo ukuran 3 x 4 cm 2 Lembar
3. Foto copy KK (Kartu Keluarga) 1 Lembar
4. Foto copy Akte Kelahiran 1 Lembar

Banyuwangi, ……………………… 2023

Mengetahui,
Orang Tua/Wali Calon Siswa,

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