MATH CLUB SEKOLAH TINGGI KEGURUAN DAN ILMU PENDIDIKAN (STKIP)

KEBANGKITAN NASIONAL– SAMPOERNA SCHOOL OFVEDUCATION (SSE)

Mulia Business Park, Building D Jln. M.T. Haryono Kav. 58-60, Pancoran, Jakarta Selatan 12780

FORMULIR PENDAFTARAN

LOMBA CERDAS – CERMAT COMATH 2012

DATA SEKOLAH

Nama sekolah : ____________________________________________________________________

Alamat sekolah : ____________________________________________________________________

____________________________________________________________________

No. Telp : ____________________________________________________________________

Alamat email : ____________________________________________________________________

Anggota 1

Nama : ____________________________________________________________________

Kelas : ____________________________________________________________________

Alamat : ____________________________________________________________________

____________________________________________________________________

Tempat & Tgl. lahir : ____________________________________________________________________

No. Telepon : ____________________________________________________________________

Alamat email : ____________________________________________________________________

Anggota 2

Nama : ____________________________________________________________________

Kelas : ____________________________________________________________________

Alamat : ____________________________________________________________________

____________________________________________________________________

Tempat & Tgl. Lahir : ____________________________________________________________________

No. Telepon : ____________________________________________________________________

Alamat email : ____________________________________________________________________

Anggota 3

Nama : ____________________________________________________________________

Kelas : ____________________________________________________________________

Alamat : ____________________________________________________________________

____________________________________________________________________

Tempat &Tgl. Lahir : ____________________________________________________________________

No. Telepon : ___________________________________________________________________

Alamat email : ____________________________________________________________________

Guru pembimbing

Nama : ____________________________________________________________________

Alamat : ____________________________________________________________________

____________________________________________________________________

Tempat & Tgl. Lahir : ____________________________________________________________________

No. Telp. : ____________________________________________________________________

Alamat email : ____________________________________________________________________

, 2012

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Guru Pembimbing