Data Siswa :
Nama Siswa : ...................................................................................
NIK : ...................................................................................
NISN : ...................................................................................
Tempat/Tanggal lahir : ...................................................................................
Jenis Kelamin : ...................................................................................
Kelas : ...................................................................................
Data Sekolah :
Nama Sekolah : ...................................................................................
NPSN : ...................................................................................
Alamat Jelas Sekolah : ...................................................................................
...................................................................................
Kecamatan : ...................................................................................
Kabupaten/Kota : ...................................................................................
Data Orangtua/Wali :
Nama Ayah Atau Ibu : ...................................................................................
NIK : ...................................................................................
Nomor HP : ...................................................................................
Alamat : ...................................................................................
...................................................................................
Desa/Kelurahan : ...................................................................................
Kab/Kota : ...................................................................................
Bandung,......./........./2024
Pengusul Pemohon
( ....................................)
Drg. MAYA HIMAWATI, Sp. Orto ( ....................................)
Catatan:
-Beasiswa ini khusus untuk yang tidak mampu
-Beasiswa ini Gratis tanpa dipungut biaya
-Penerima beasiswa PIP ini sesuai kriteria dari Kemdikbud.
-Wajib diisi lengkap data pengajuan diatas