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Formulir Pendaftaran PPDB MAN 1 Sambas TP 2020/2021

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KEMENTERIAN AGAMA REPUBLIK INDONESIA

MADRASAH ALIYAH NEGERI 1 SAMBAS


Jalan Raya Sejangkung Kawasan Pendidikan Tinggi Sambas  (0562) 6303089

FORMULIR PENDAFTARAN PESERTA DIDIK BARU

I. Identitas Pribadi Siswa


Nama Lengkap : ................................................................................
NISN : ................................................................................
Foto Berwarna
NIK (No.Induk Kependudukan) Siswa : ................................................................................
3x4
Tempat/Tgl.Lahir : ................................................................................
Jenis Kelamin : ................................................................................
Hobi : ................................................................................
Cita-cita : ................................................................................................................
Jumlah Saudara : ................................................................................................................
Jarak Rumah ke Sekolah : ................................................................................................................
Transportasi dari Rumah ke Sekolah : ................................................................................................................

II. Asal Sekolah pada Jenjang Sebelumnya (SMP/MTs/Sederajat)


Nama Sekolah (SMP/MTs) : ................................................................................................................
Status Sekolah (Negeri/Swasta) : ................................................................................................................
Alamat Sekolah (SMP/MTs) : ................................................................................................................

III.Informasi Alamat Orang Tua/Wali Siswa


Alamat : ................................................................................................................
Desa / Kelurahan : ................................................................................................................
Kecamatan : ................................................................................................................
Kabupaten / Kota : ................................................................................................................
Provinsi : ................................................................................................................
Kode Pos : ................................................................................................................
Nomor HP/WA yang dapat dihubungi : ............................................atas nama …..............................................
IV.Informasi Orang Tua / Wali Siswa
No. Kartu Keluarga : ................................................................................................................
A. Ayah
Nama Lengkap : ................................................................................................................
NIK/No.KTP : ................................................................................................................
Pendidikan Terakhir : ................................................................................................................
Pekerjaan : ................................................................................................................
B. Ibu
Nama Lengkap : ................................................................................................................
NIK/No.KTP : ................................................................................................................
Pendidikan Terakhir : ................................................................................................................
Pekerjaan : ................................................................................................................
Rata-rata Penghasilan Per Bulan : ................................................................................................................
No.KPS (Kartu Perlindungan Sosial) : ................................................................................................................
No.PKH (Program Keluarga Harapan) : ................................................................................................................
No.KIP (Kartu Indonesia Pintar) : ................................................................................................................
Formulir Pendaftaran PPDB MAN 1 Sambas TP 2020/2021 1
V. Prestasi Yang Pernah di raih Siswa
Bidang Prestasi : ................................................................................................................
Tingkat Prestasi : ................................................................................................................
Peringkat yang di raih : ................................................................................................................
Tahun Meraih Prestasi : ................................................................................................................

Data tersebut di atas telah kami isi sesuai keadaan yang sesungguhnya dan sejujurnya guna membantu proses
yang diperlukan.

Mengetahui Sambas, ……………………. 2020


Orang Tua/Wali Siswa Calon Peserta Didik

(……………………………………) (……………………………………)
Tanda Tangan & Nama Lengkap Tanda Tangan & Nama Lengkap

Formulir Pendaftaran PPDB MAN 1 Sambas TP 2020/2021 2

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