DINAS PENDIDIKAN KABUPATEN LEBAK
SMK NEGERI 1 CURUGBITUNG
Kp. Gobang Ds. Mayak
Kec. Curugbitung Kab Lebak – Banten 42381
I.
IDENTITAS PESERTA DIDIK
1.
Nomor pendaftaran : .................................................................................
2.
Nama Lengkap : ................................................................................
3.
Jenis Kelamin : .................................................................................
4.
NISN
: .............................................................................
5.
Tempat / Tanggal Lahir : ..................................................................................
6.
Agama
: ..............................................................................
7.
Anak ke : ..............................................................................
8.
Anak Yatim/Piatu/Yatim
Piatu : .................................................................................
9.
Jarak dari rumah ke
sekolah : .................................................................................
10.
Kode Pos : .............................................................................
11.
Alamat
: ...............................................................................
II.
IDENTITAS ORANG TUA/WALI
1.
Nama Ayah Kandung : .................................................................................
2.
Tempat/Tanggal Lahir Ayah : .................................................................................
3.
Pekerjaan Ayah : ................................................................................
4.
Pendidikan terakhir ayah : .................................................................................
5.
Penghaslan ayah perbulan : .................................................................................
6.
Nama Ibu Kandung : ..................................................................................
7.
Tempat / tanggal lahir Ibu : .................................................................................
8.
Pekerjaan Ibu : ................................................................................
9.
Pendidikan Terakhir Ibu : .................................................................................
10.
Penghasilan Ibu perbulan : .................................................................................
11.
Alamat Orang Tua : ..................................................................................
III.
KETERANGAN PENDIDIKAN
A.
ASAL SEKOLAH
1.
SMP/MTs : ...................................................................................
2.
Nomor Ijazah : ...................................................................................
B.
PINDAHAN
1.
SMA/SMK/MAK : ...............................................................................
2.
Tanggal dan Nomor Surat Pindah
: .........................................................................
3.
Tanggal Diterima : ...................................................................................
4.
Alasan Pindah : ....................................................................................
IV.
PROGRAM KEAHLIAN YANG DIMINATI
(Lingkari)
a.
Agribisnis (Pertanian)
b.
Marketing (Pemasaran)
V.
CATATAN LAINNYA :..........................................................................................................
.........................................................................................................................................
Formulir diserahkan paling lambat tanggal 12 Juli 2014, dan calon siswa harus
hadir pada tanggal ... Juli 2014
Calon Siswa
( ………………………………… )
Curugbitung, ………………………….. 2014
Orang Tua Siswa
( ……………………………………………… )
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