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Formulir pendaftaran siswa baru sma ibnu sina 2013
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Formulir pendaftaran siswa baru sma ibnu sina 2013

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  • 1. YAYASAN PENDIDIKAN ISLAM SEKOLAH MENENGAH ATAS (SMA) IBNU SINA BRAJA SELEBAH LAMPUNG TIMUR STATUS TERAKREDITASI NDS. L. 02074005 NPSN. 10806031 NSS. 302120416023 Jl. Kampus Ibnu Sina Po. Box 02 Braja Harjosari Kec. Braja Selebah Lampung Timur 34196  0725-7643037 FORMULIR PENDAFTARAN SISWA BARU Nomor Pendaftaran : ……………………….A. IDENTITAS SISWA : 1. Nama Lengkap (sesuai Ijazah) : ………………………………………………....................... 2. Jenis Kelamin : …………………………………………………................... 3. Tempat & Tanggal Lahir : …………………………………………………................... 4. Agama : …………………………………………………................... 5. Alamat Sekarang : ………………………………………………....................... 6. Sekolah Asal : a. Nama Sekolah : …………………………………………………................... b. Alamat Sekolah : …………………………………………………................... 7. Nomor Peserta Berdasarkan NISN : ………………………………………………………………. 8. Nomor Peserta Ujian SMP/ MTS : ………………………………………………………………. 9. Nomor STTB / Tahun Lulus : ………………………………………………………………. 10. Nomor SKHUN : …………………………………………………................... 11. Jumlah Nilai STTB/ rata-rata : ……………………………………………….......................B. IDENTITAS ORANG TUA (AYAH) : 1. Nama Ayah : ………………………………………………………………. 2. Tempat & Tanggal Lahir : ………………………………………………………………. 3. Agama : ………………………………………………………………. 4. Pekerjaan : ………………………………………………………………. 5. Alamat Sekarang : ……………………………………………………………….C. IDENTITAS ORANG TUA ( IBU ) : 1. Nama Ibu : ………………………………………………………………. 2. Tempat & Tanggal Lahir : ………………………………………………………………. 3. Agama : ………………………………………………………………. 4. Pekerjaan : ………………………………………………………………. 5. Alamat Sekarang : ………………………………………………………………. Braja Selebah, ………………….2013, Panitia PMB, Calon Siswa, Pas Foto 3X4 _________________ ____________________ Mengetahui Kepala Sekolah, Drs. H. HASAN ALI

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