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YAYASAN PENDIDIKAN BUDI UTOMOSEKOLAH MENENGAH ATAS BUDI UTOMOSTATUS TERAKREDITASI A NSS 304050405053

JL. MASHUR GADING MANGU PERAK JOMBANG JATIM 61461 0321-860816

FORMULIR PENDAFTARAN SISWA BARUN omo P!"#$%&$ $" '(((((((((..

Catatan: T)*+, #!" $" ) )%/$ +&$*

o !& $" &+#$/! *)

A. IDENTITAS SISWA

1. N$m$ L!" /$ ,!,)$+ + $ $ 7'.....................................................................................................

2. J!"+, K!*$m+"'.....................................................................................................

3. T!m $& T$" $* L$ +' .....................................................................................................

4. A $m$' .....................................................................................................

5. A*$m$& A,$*' .....................................................................................................

6. A*$m$& #+ Jom9$" ' .....................................................................................................

Ko,& ' .....................................................................................................

Po"#o/ G$m$ 1:G$m$ 27' .....................................................................................................

;. S!/o*$ A,$*' ..................................................................................................... N$m$ S!/o*$

' ..................................................................................................... A*$m$& S!/o*$

' .....................................................................................................8. Nomo NISN' .....................................................................................................

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2. T!m $& T$" $* L$ +' .....................................................................................................

3. A $m$ ' .....................................................................................................

4. P!/! $$"' .....................................................................................................

5. A*$m$& S!/$ $"' .....................................................................................................

C. IDENTITAS ORANG TUA (IBU) :

1. N$m$ I9)' .....................................................................................................

2. T!m $& T$" $* L$ +' .....................................................................................................

3. A $m$ ' .....................................................................................................

4. P!/! $$" ' .....................................................................................................

5. A*$m$& S!/$ $"' .....................................................................................................

Jom9$" =.............................2014

>$*o" S+,?$=

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