Form PM. 7.5.1/L1 Rev.0

FORMULIR PENDAFTARAN CALON SISWA BARU

TAHUN PELAJARAN 2014/2015

A. KETERANGAN PRIBADI1. Nama : ....................................................................................................................................2. JenisKelamin : ....................................................................................................................................3. Tempat/ TanggalLahir : ....................................................................................................................................4. Agama : ....................................................................................................................................5. AlamatAsal : ....................................................................................................................................6. AlamatSekarang : ....................................................................................................................................7. No. Telepon/HP : ....................................................................................................................................

B. PENDIDIKAN1. Sekolah Asal : ....................................................................................................................................2. Ijazah Terakhir : ....................................................................................................................................3. Tanggal/ No. STK : ....................................................................................................................................4. Alamat Sekolah : ....................................................................................................................................

C. ORANG TUA1. Nama Orang Tua : a. Ayah : ....................................................................................

b. Ibu : ....................................................................................2. Pekerjaan Orang Tua : ....................................................................................................................................3. Keadaan Orang Tua : a. Ayah : Masih Hidup/ Sudah Meninggal

b. Ibu : Masih Hidup/ Sudah Meninggal4. Alamat Orang Tua : ....................................................................................................................................5. Nama Wali Siswa : ....................................................................................................................................6. Alamat Wali : ....................................................................................................................................7. No. Telepon/HP : ....................................................................................................................................

D. SYARAT-SYARAT DAN YANG DILAMPIRKAN1. Persyaratan Tetap :

No Syarat-syarat Banyak Ada Tidak Ada1 Surat Keterangan Aktif 1 Lembar

2. Foto copyPiagam penghargaan (Tk.Kabupaten/Provinsi/Nasional) 1 Lembar

3. Pas Photo ukuran3x4 Cmhitamputih 2 Lembar

4. Surat Keterangan Berbadan Sehat dari dokter/puskesmas/RSUD 1 Lembar

5. Foto copyRaportKelas1-3 (semester I –V) yang dilegalisir 1 Lembar

2. Test FisikNo. Keadaan Fisik Data Fisik Keterangan

1. Tato Ya Tidak

2. Tindik Ya Tidak

3. Tinggi Badan ... Cm.

4. Berat Badan ... Kg.

Catatan- Mengisi tabel/ Kolom ada/ tidak ada adalah panitia PSB- Mengisi Data Pribadi harus sesuai dengan ijazah / STK / SKHU SMP- Calon siswa hanya mengisi data bagian atas, tandatangan wali/ orangtua dan calon siswa

Sampit,……………………….Mengetahui,

Orang Tua/Wali Calon Siswa,

(………………………………) (……………………………..)