Format PPDB
- 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