PEMERINTAH KABUPATEN BIMA

DINAS PENDIDIKAN, KEBUDAYAAN, PEMUDA DAN OLAHRAGA

SMP NEGERI 2 AMBALAWI
Alamat: Jalan lintas Talapiti-Desa Talapiti Kec.Ambalawi Kab.Bima Email: smpn2.ambalawi@gmail.com

FORMULIR PENDAFTARAN SISWA BARU

TAHUN PELAJARAN 2022/2023
1. Nama :.........................................................................................
2. Jenis Kelamin :.........................................................................................
3. NISN SD (Tanyakan Pada Guru SDN Masing-Masing) :....................................................................................... PAS FOTO
4. NIK (Berdasakan KK) :......................................................................................... 3x4

5. Tempat Tanggal Lahir :.........................................................................................

6. Agama :.........................................................................................
7. Status Dalam Keluarga :.........................................................................................................................
8. Anak Ke :.........................................................................................................................
9. Jumlah Saudara Kandung :.........................................................................................................................
10. Sekolah Asal :.........................................................................................................................
11. Identitas Orang Tua Wali
 Nama Bapak :.........................................................................................................................
Tempat Tanggal Lahir :.........................................................................................................................
Pendidikan Terakhir :.........................................................................................................................
Pekerjaan :.........................................................................................................................
Penghasilan Bulanan :.........................................................................................................................
 Nama Ibu :.........................................................................................................................
Tempat Tanggal Lahir :.........................................................................................................................
Pendidikan Terakhir :.........................................................................................................................
Pekerjaan :.........................................................................................................................
Penghasilan Bulanan :.........................................................................................................................
Harap di isi jika Tinggal Bersama Wali:
 Nama Wali :.........................................................................................................................
Tempat Tanggal Lahir :.........................................................................................................................
Pendidikan Terakhir :.........................................................................................................................
Pekerjaan :.........................................................................................................................
Penghasilan Bulanan :.........................................................................................................................
12. Tinggal Bersama :( )Bersama Ornag Tua, ( )Wali, ( )Asrama, ( )Panti asuhan ***Berikan Tanda Centang

13. Alamat :.........................................................................................................................

RT/RW :.........................................................................................................................
Desa/Kelurahan :.........................................................................................................................
Kode Pos :.........................................................................................................................
Kecamatan :.........................................................................................................................
Kabupaten/Kota :.........................................................................................................................
Provinsi :.........................................................................................................................
14. Tinggi Badan/Berat Badan :.......................................................................................................................
15. No Telepon/HP :.........................................................................................................................
16. Jarak Tempat Tingal ke-Sekolah :.............................................................................................................
17. Alat Transportasi Ke-Sekolah :.............................................................................................................
18. E-mail :.............................................................................................................

LAMPIRKAN PERSYARATAN

 Foto Copy Ijazah SD yang dilegalisir sebanyak 1 (satu) lembar (Menyusul).

 Foto Copy SKHUN SD yang dilegalisir sebanyak 1 (satu) lembar (Menyusul).
 Foto Copy Kartu Peserta Ujian Nasional SD sebanyak 1 (satu) lembar. (Wajib ada)
 Pas Foto Hitam Putih 3X4 sebanyak 2 (dua) lembar. (Wajib ada)
 Foto Copy Kartu Keluarga (KK) sebanyak 1 (satu) lembar. (Wajib ada)
 Foto Copy Kartu Perlindungan Sosial (KPS) sebanyak 1 (satu) lembar (Apabila Ada).
 Foto Copy Kartu Keluarga Sejahtera (KKS/PKH) sebanyak 1 (satu) lembar (Apabila Ada).
 Foto Copy Kartu Indonesia Pintar (KIP) sebanyak 1 (satu) lembar (Apabila Ada).

Talapiti, Juli 2022

Orang Tua/Wali Siswa, Siswa Yang Bersangkutan,

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