FORMULIR PENDAFTARAN SISWA BARU

KEMENTERIAN AGAMA

MADRASAH ALIYAH NEGERI RANCAH

KABUPATEN CIAMIS

Jl. Rumah Sakit No. 20 Desa Situmandala Kec. Rancah Kab. Ciamis 46387 Telp/Fax. 0265 2732379

FORMULIR BIODATA SISWA MAN RANCAHMohon semua diisi dengan lengkap!NOMOR IDENTITAS

Nomor Peserta Ujian MTs/SMP: ............................................................................

NISN

: ............................................................................

Nomor STTB/Ijazah

: ............................................................................

Nomor SKHUN

: ............................................................................IDENTITAS SISWANama lengkap

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

: ............................................................................

Tempat, Tgl Lahir: ............................................................................Umur

: ............................................................................Agama

: ............................................................................Hobi

: ............................................................................Cita-cita

: ............................................................................Jarak Ke Sekolah

: ............................................................................Alat Transportasi

: ............................................................................StatusKeluarga: Anak Kandung/Tiri/Lainnya)*Jumlah Saudara

: Kandung ...................................... Tiri ......................................Penerima BSM

: Ya/Bukan)*IDENTITAS ORANG TUA/WALI

Nama Orang Tua

: Ayah ...................................... Ibu ......................................Pendidikan

: Ayah ...................................... Ibu ......................................

Pekerjaan

: Ayah ...................................... Ibu ......................................Penghasilan

: Ayah ...................................... Ibu ......................................Agama

: Ayah ...................................... Ibu ......................................

Alamat

: Dusun.........................................RT/RW .......... ......No...............

Desa................................Kec. ............... ..........Kab. ...................

No. Telp/HP

: ............................................................................No. Kartu Keluarga: ............................................................................IDENTITAS SEKOLAH ASALNama Sekolah Asal

: ............................................................................................................................................Status Sekolah

: Negeri/Swasta/Paket C/Pesantren)*Alamat Sekolah

: ............................................................................................................................................Tanggal/Bulan/Tahun Lulus: ............................................................................................................................................Nilai Rata-rata Ujian

: ............................................................................................................................................PRESTASI YANG DIMILIKI

Bidang Akademis

: ............................................................................................................................................Bidang Olah Raga

: ............................................................................................................................................Bidang Kesenian

: ............................................................................................................................................Bidang Keagamaan

: ............................................................................................................................................Bidang Lainnya

: ............................................................................................................................................)* coret yang tidak perlu

Mengetahui :

Orang Tua/ Wali Siswa

.............................................................................................., ..............................2014Siswa,

..............................................................

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