1. DATA IDENSTITAS PESERTA DIDIK BARU
SMP NEGERI SATAP 9 PRAYA TIMUR
TAHUN PELAJARAN 2015/2016
1. Nama Lengkap :......................................................................................................................................
2. NamaPanggilan :......................................................................................................................................
3. JenisKelamin :......................................................................................................................................
4. NISN :......................................................................................................................................
5. NIK :......................................................................................................................................
6. Tempatdantanggallahir :......................................................................................................................................
7. Asal sekolah(SD/MI) :......................................................................................................................................
8. NomorSKHU :......................................................................................................................................
9. Tanggal diterimadisekolah ini :......................................................................................................................................
10. Jika pindahansebutkanalasanpindahkesekolahini:............................................................................................................
11. Agama :......................................................................................................................................
12. Alamat :
a. Jalan :......................................................................................................................................
b. RT :......................................................................................................................................
c. RW :......................................................................................................................................
d. Dusun :......................................................................................................................................
e. Desa :......................................................................................................................................
f. Kecamatan :......................................................................................................................................
g. KodePos :......................................................................................................................................
13. Tinggal bersama (lingkarisalahsatu):
a. Orangtua
b. Wali
c. Kost (mondok)
d. Lainnya
14. Transportasikesekolah (lingkari salahsatu):
a. Angkutan umum
b. Ojek
c. Sepeda
d. Kendaraanpribadi/antar jemput
e. Lainnya
15. No telepon :......................................................................................................................................
16. No HP :......................................................................................................................................
17. NomorKPS (Kartu PerlindunganSosial)bagiyangmemiliki : ...............................................................................................
18. Data Ayah Kandung:
a. Nama :......................................................................................................................................
b. TahunLahir :......................................................................................................................................
c. Pendidikan :......................................................................................................................................
d. Pekerjaan :......................................................................................................................................
e. Penghasilanperbulan (lingkarisalahsatu)
1. Kurangdari Rp500.000,-
2. Rp 500.000 – Rp999.999
3. Rp 1.000.000 – Rp1.999.999
4. Rp 2.000.000 – Rp. 4.999.999
5. Rp 5.000.000 – Rp20.000.000
19. Data Ibu Kandung:
a. Nama :......................................................................................................................................
b. TahunLahir :......................................................................................................................................
c. Pendidikan :......................................................................................................................................
d. Pekerjaan :......................................................................................................................................
2. e. Penghasilanperbulan(lingkarisalahsatu)
1. Kurangdari Rp500.000,-
2. Rp 500.000 – Rp999.999
3. Rp 1.000.000 – Rp1.999.999
4. Rp 2.000.000 – Rp. 4.999.999
5. Rp 5.000.000 – Rp20.000.000
20. Data Wali:
a. Nama :......................................................................................................................................
b. TahunLahir :......................................................................................................................................
c. Pendidikan :......................................................................................................................................
d. Pekerjaan :......................................................................................................................................
e. Penghasilanperbulan(lingkarisalah satu)
1. Kurangdari Rp500.000,-
2. Rp 500.000 – Rp999.999
3. Rp 1.000.000 – Rp1.999.999
4. Rp 2.000.000 – Rp. 4.999.999
5. Rp 5.000.000 – Rp20.000.000
21. Data Periodik:
a. Tinggibadan : ………………..cm
b. Berat badan : ………………..kg
c. Jarak rumahkesekolah : ……………..…km
22. Data Kesehatan :
a. Pernahmenderitapenyakit : Cacar TBC Lever Malaria Lainnya
b. Golongandarah : O A B AB
23. Jumlahsaudarakandung : ………………….orang
24. Kegemaran :
a. Kesenian :......................................................................................................................................
b. Olahraga :......................................................................................................................................
c. Organisasi :......................................................................................................................................
d. Lain-lain :......................................................................................................................................
25. Prestasi :
Jenis Prestasi Tingkat Prestasi Nama Prestasi Tahun Penyelenggara
26. Beasiswa
Jenis Beasiswa Keterangan Tahun Mulai Tahun Selesai
BSM
BeasiswaPrestasi
Beasiswa ………………
Beasiswa………………
Beasiswa………………
Denganinisaya menyatakanbahwadata
yang saya isi pada formulirinibenar.
________________,____,Juni 2015
OrangTua/Wali
____________________________
(Namaterang)
Harap dilengkapi dengandokumenpendukung:
1. Ijazah
2. Akte Kelahiran
3. Kartu Keluarga
4. KPS(KartuPerlindunganSosial) bagi yang
memiliki
