Formulir PPDB MIS Kertijayan TP 2013-2014
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NIS : 110600 NSM : 11123326007 ( TERAKREDITASI A ) Alamat : Kertijayan Gang 2 No. 03 Rt.06 Rw.02 Telp. (0285) 433363 Pekalongan email : [email protected] FORMULIR PPDB MIS KERTIJAYAN TAHUN PELAJARAN 2013/2014 Dimohon untuk diisi selengkap-lengkapnya ! PESERTA DIDIK / MURID 1. Nama : ................................................................................................... 2. Jenis Kelamin : .................................................................................................. 3. Tempat / Tanggal Lahir : .................................................................................................. 4. Anak Ke – : .................................................................................................. 5. Jumlah Saudara : .................................................................................................. 6. Alamat : .................................................................................................. ORANG TUA / WALI 1. Nama Orang Tua a. Bapak : .................................................................................................. b. Ibu : .................................................................................................. 2. Pendidikan a. Bapak : .................................................................................................. b. Ibu : .................................................................................................. 3. Pekerjaan a. Bapak : .................................................................................................. b. Ibu : .................................................................................................. 4. Alamat : .................................................................................................. 5. Nama Wali : .................................................................................................. 6. Pendidikan : .................................................................................................. 7. Pekerjaan : .................................................................................................. 8. Alamat : .................................................................................................. 9. No. Telp/Hp : .................................................................................................. MASUK MADRASAH INI 1. Asal Sekolah/Madrasah : .................................................................................................. 2. Diterima Tanggal : .................................................................................................. 3. Diterima di Kelas : .................................................................................................. 4. Surat Pindah : .................................................................................................. Kertijayan, Juli 2013 Yang Mendaftarkan Petugas Pendaftar (…………………………….…) (…….………………………) Foto 3 X 4 Foto 3 X 4
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Formulir PPDB MIS Kertijayan Buaran Kab. Pekalongan
Transcript of Formulir PPDB MIS Kertijayan TP 2013-2014
NIS : 110600 NSM : 11123326007 ( TERAKREDITASI A )
Alamat : Kertijayan Gang 2 No. 03 Rt.06 Rw.02 Telp. (0285) 433363 Pekalongan email : [email protected]
FORMULIR PPDB MIS KERTIJAYAN TAHUN PELAJARAN 2013/2014
Dimohon untuk diisi selengkap-lengkapnya !
PESERTA DIDIK / MURID
1. Nama : ...................................................................................................
2. Jenis Kelamin : ..................................................................................................
3. Tempat / Tanggal Lahir : ..................................................................................................
4. Anak Ke – : ..................................................................................................
5. Jumlah Saudara : ..................................................................................................
6. Alamat : ..................................................................................................
ORANG TUA / WALI
1. Nama Orang Tua
a. Bapak : ..................................................................................................
b. Ibu : ..................................................................................................
2. Pendidikan
a. Bapak : ..................................................................................................
b. Ibu : ..................................................................................................
3. Pekerjaan
a. Bapak : ..................................................................................................
b. Ibu : ..................................................................................................
4. Alamat : ..................................................................................................
5. Nama Wali : ..................................................................................................
6. Pendidikan : ..................................................................................................
7. Pekerjaan : ..................................................................................................
8. Alamat : ..................................................................................................
9. No. Telp/Hp : ..................................................................................................
MASUK MADRASAH INI
1. Asal Sekolah/Madrasah : ..................................................................................................
2. Diterima Tanggal : ..................................................................................................
3. Diterima di Kelas : ..................................................................................................
4. Surat Pindah : ..................................................................................................
Kertijayan, Juli 2013
Yang Mendaftarkan Petugas Pendaftar
(…………………………….…) (…….………………………)
Foto
3 X 4
Foto
3 X 4
