A. IDENTITAS SISWA
1. Nama Siswa (Lengkap) : .................................................................................................................................
2. Jenis Kelamin : a. Laki - laki b. Perempuan
Phas Photo 3. Tempat dan Tanggal Lahir : .................................................................................................................................
Tempel Ukuran 4. Agama : a. Islam b. ..................
3 x 4 Cm
Hitam Putih 5. Kewarganegaraan : a. Indonesia b. ..................
6. Anak Ke : ......................................................
7. Status dalam keluarga : a. Anak Kandung b. Anak Angkat c. Anak Tiri
8. Jumlah Saudara : a. Kandung ............. Orang b. Angkat ................ Orang c. Tiri ............ Orang
9. Katagori Orang Tua Siswa : a. Mampu b. Miskin c. Yatim d. Piatu e. Yatim Piatu
10. Tinggal dengan : a. Orang Tua b. Asrama/Kost c. Famili
11. Jarak Rumah ke Madrasah : .............................................. Km
12. Golongan Darah : A / B / AB / O
13. Tinggi dan Berat Badan : Tinggi ............... Cm Barat ....................... Kg
14. Penyakit pernah diderita : .................................................................................................................................
15. Kegemaran/Hobi : .................................................................................................................................
Phas Photo 16. Kegiatan Kemasyarakatan : .................................................................................................................................
Tempel Ukuran 17. Alamat Siswa (lengkap) : .................................................................................................................................
3 x 4 Cm
Hitam Putih 18. Nomor Telepo/HP : .................................................................................................................................
B. PENDIDIKAN SISWA
1. Siswa Baru : .................................................................................................................................
a. Sekolah Asal : .................................................................................................................................
b. Nomor Ijazah/STTB : .................................................................................................................................
c. Nomor STL/SKHUN : .................................................................................................................................
d. Tanggal STTB/SKHUN : .................................................................................................................................
e. Diterima di Kelas : .................................................................................................................................
f. Pada Tanggal : .................................................................................................................................
g. Menerima Beasiwa : Tahun : ........................ Kelas : ....................... Dari : ..................................
Phas Photo
Tempel Ukuran 2. Siswa Pindahan
3 x 4 Cm a. Nomor Ijazah/STTB : .................................................................................................................................
Hitam Putih
b. Nomor Ijazah/STTB : .................................................................................................................................
c. Nomor STL/SKHUN : .................................................................................................................................
d. Diterima di Kelas : .................................................................................................................................
e. Tanggal diterima : .................................................................................................................................
f. Menerima Beasiwa : Tahun : ........................ Kelas : ....................... Dari : ..................................
EH BARAT
NOMOR INDUK SISWA : ..............................
...../......... siswa ...../......... siswa ...../......... siswa ...../......... siswa ...../......... siswa ...../......... siswa
................. Hari ................. Hari ................. Hari ................. Hari ................. Hari ................. Hari
................. Hari ................. Hari ................. Hari ................. Hari ................. Hari ................. Hari
................. Hari ................. Hari ................. Hari ................. Hari ................. Hari ................. Hari