1 Nama Lengkap : .................................................................................................................2 Tempat,Tanggal Lahir : .................................................................................................................3 Jenis Kelamin : .................................................................................................................4 Agama : .................................................................................................................5 Alamat : RT :................... RW : ................. Kampung :.............................................

: Desa :......................................... Kecamatan :..........................................: Kode Post :...................................................

6 Asal Sekolah : .................................................................................................................7 Alamat Sekolah : .................................................................................................................8 NISN : .................................................................................................................9 No Peserta UN : .................................................................................................................10 Nilai UN : B. Indonesia : ......

: Matematika : ......: B. Inggris : ..........

11 Nilai UN IPA : .................................................................................................................12 Jumlah Nilai UN : .................................................................................................................13 Tahun Surat Tanda Lulus : .................................................................................................................14 Nomor Surat Tanda Lulus : .................................................................................................................15 Nama Ayah : .................................................................................................................

Pekerjaan : .................................................................................................................16 Nama Ibu : .................................................................................................................

Pekerjaan : .................................................................................................................17 Alamat Orang Tua : .................................................................................................................18 Nama Wali : .................................................................................................................

Alamat : .................................................................................................................19 Cita-Cita : 1. ..........

: 2. .........: 3. .........

20 Minat Jurusan Yang di Pilih : IPA/IPS*

IDENTITAS SISWA

FORMULIR PENDAFTARANCALON PESERTA DIDIK BARUTAHUN PELAJARAN 2014/2015

PEMERINTAH KABUPATEN LEBAKDINAS PENDIDIKAN DAN KEBUDAYAAN

Jalan Warungkadu No. 49 Cikotok-Cibeber Kode Post 42394 No HP. 087871690513SMA NEGERI I CIBEBER

MengetahuiOrang Tua/Wali Cibeber, ............................. 2014

Calon Siswa

(......................................................) (......................................................)

*) Coret Yang Tidak Dipilih

FORMULIR PENDAFTARANCALON PESERTA DIDIK BARUTAHUN PELAJARAN 2014/2015