yayasan pendidikan budi utomo

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  • 8/17/2019 Yayasan Pendidikan Budi Utomo

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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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