FORMULIR SISWA BARU JALUR PRESTASI TAHUN PELAJARAN 2011-2012

YAYASAN PENDIDIKAN ISLAM MATHLA’UL ANWAR

MTs. MATHLA’UL ANWAR 2 KOTA BOGOR

NSM : 121232710027

Akte Notaris No. 4 Tgl. 6 Februari 1999

BUHARI, SH.

 

     Alamat : KH. Sholeh Iskandar Pabuaran Rt.05/03 Cibadak kec. Tanah Sareal Kota Bogor 16166

        Email : mts.mathlaulanwar2bogor@yahoo.com Tlp. (0251) 7532802- 7543124

  

FORMULIR PENDAFTARAN CALON SISWA/I BARU

TAHUN PELAJARAN 2011/2012

A.       KETERANGAN IDENTITAS CALON SISWA :

1.         Nama (harus sesuai dengan ijazah)  : ..............................................................................

2.        Tempat dan tanggal lahir                  : Kota .......................Tgl. ........ Bln. ....... Thn. ........
3.    Agama                                : ......................Jenis Kelamin: .......................

4.        Anak ke                                            : .....................Jumlah Saudara : ..................... orang.

5.        Alamat                                              : Jln. ......................... Rt. .......... Rw. .......... No. .....
                                                                   Kelurahan ........................Kecamatan ......................
                                                                   Kab/Kota ..........................Telp/HP. .......................

B.       KETERANGAN PENDIDIKAN CALON SISWA/I :

1.         Nama Sekolah Asal                                 : ....................................................................................................

2.        Alamat Sekolah Asal                               : ....................................................................................................

3.        NISN Sekolah Asal                                 : Nomor ........................................................................................

4.        Nomor / Tanggal / Tahun Ijazah         : Nomor ...........................................Tgl. ....... Bln. ...... Thn. ...........

5.        Nomor / Tanggal / Tahun / STL             : Nomor ........................................ Tgl. ............ Bln. ....... Thn. ......

6.        Nilai Ijazah / STL / STTB                        : Bhs. Indonesia : ...... Matematika : ...... IPA : ........PAI : .......

C.      KETERANGAN KELUARGA :

7.         Ayah :      Nama                                      : .............................................................................................................

Agama                                      : ......................................... Pendidikan Terakhir : ............................

Pekerjaan                                  : ......................................... Penghasilan ...........................................

Alamat                                    : Jln. ......................................................... Rt. ................... Rw. .............

                                                  Kelurahan : ................................. Kecamatan .....................................

  Kab./Kota : ..................................... Telp/HP..................................

8.        Ibu :        Nama                                      : ................................................................................................................

Agama                                     : .................................................... Pendidikan Terakhir : ..................

Pekerjaan                                : ................................................... Penghasilan ....................................

Alamat                                    : Jln. .............................................................. Rt. ................... Rw. .........

                                                  Kelurahan : .................................... Kecamatan ...................................

Kab./Kota : ......................................... Telp/HP. ................................

9.        Wali :      Nama                                      : ................................................................................................................

Agama                                     : ..................................................... Pendidikan Terakhir : .....................

Pekerjaan                                : ...................................................... Penghasilan ....................................

Alamat                                    : Jln. ....................................................... Rt. ................... Rw. ...................

                                                  Kelurahan : ....................................... Kecamatan ....................................

  Kab./Kota : ..................................................... Telp/HP. ......................

Hubungan dengan wali                           : ....................................................................................................................

D.      KETERANGAN LAIN-LAIN :

10.      Kegemaran / Hobby                               : ...................................................................................................................

11.       Mata Pelajaran yang disukai                : ..................................................................................................................

12.      Keistimewaan pada anggota tubuh      : ..................................................................................................................

13.      Penyakit kronis yang pernah diderita     : ..............................................................................................................
                                                                                                                     Bogor, ......................................................

Mengetahui dan menyetujui

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