Biodata O2sn Smp 2019.docx
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PEMERINTAH KABUPATEN KUBU RAYA
DINAS PENDIDIKAN DAN KEBUDAYAAN Jalan Adisucipto, Km. 15,2
SUNGAI RAYA
==================================================================
BIODATA PESERTA OLIMPIADE OLAHRAGA SISWA NASIONAL ( O 2 S N ) SMP TAHUN 2019 KABUPATEN KUBU RAYA
CABANG LOMBA
: .......................................................
1. N A M A LENGKAP
: ........................................................................................
2. TEMPAT TANGGAL LAHIR
: ........................................................................................
3. ASAL SEKOLAH
: ........................................................................................
4. N I S N
: .......................................................................................
5. KELAS
: ........................................................................................
6. ALAMAT SEKOLAH
: ........................................................................................
7. NO TELPON SEKOLAH
: ........................................................................................
8. ALAMAT RUMAH
: ........................................................................................
9. NOMOR HP
SISWA
10. ORANG TUA
: . ........................................................................................ : ........................................................................................
A. NAMA AYAH
: ........................................................................................
B. PEKERJAAN
: ........................................................................................
A. NAMA I B U
: ........................................................................................
B. PEKERJAAN
: ......................................................................................... Sungai Kakap,
Foto 3 x 4
Foto 3 x 4
......................................................
CATATAN : Mohon di tulis dengan huruf Cetak *) Coret yang tidak perlu
PEMERINTAH KABUPATEN KUBU RAYA
DINAS PENDIDIKAN DAN KEBUDAYAAN Jalan Adisucipto, Km. 15,2
SUNGAI RAYA
==================================================================
BIODATA PENDAMPING OLIMPIADE OLAHRAGA SISWA NASIONAL ( O 2 S N ) SMP TAHUN 2019 KABUPATEN KUBU RAYA 1. N A M A LENGKAP
: ........................................................................................
2. TEMPAT TANGGAL LAHIR
: ........................................................................................
3. ASAL SEKOLAH
: ........................................................................................
4. NIP
: .......................................................................................
5. PENDIDIKAN
: ........................................................................................
6. MENGAJAR BIDANG STUDI
: ........................................................................................
7. ALAMAT SEKOLAH
: ........................................................................................
8. NO TELPON SEKOLAH
: ........................................................................................
9. ALAMAT RUMAH
: ........................................................................................ : ........................................................................................
10. NOMOR HP PENDAMPING
: . ........................................................................................ Sungai Kakap,
Foto 3 x 4
NAMA PENDAMPING
Foto 3 x 4
....................................................
CATATAN : Mohon di tulis dengan huruf Cetak *) Coret yang tidak perlu
DINAS PENDIDIKAN DAN KEBUDAYAAN Jalan Adisucipto, Km. 15,2
SUNGAI RAYA
==================================================================
BIODATA PESERTA OLIMPIADE OLAHRAGA SISWA NASIONAL ( O 2 S N ) SMP TAHUN 2019 KABUPATEN KUBU RAYA
CABANG LOMBA
: .......................................................
1. N A M A LENGKAP
: ........................................................................................
2. TEMPAT TANGGAL LAHIR
: ........................................................................................
3. ASAL SEKOLAH
: ........................................................................................
4. N I S N
: .......................................................................................
5. KELAS
: ........................................................................................
6. ALAMAT SEKOLAH
: ........................................................................................
7. NO TELPON SEKOLAH
: ........................................................................................
8. ALAMAT RUMAH
: ........................................................................................
9. NOMOR HP
SISWA
10. ORANG TUA
: . ........................................................................................ : ........................................................................................
A. NAMA AYAH
: ........................................................................................
B. PEKERJAAN
: ........................................................................................
A. NAMA I B U
: ........................................................................................
B. PEKERJAAN
: ......................................................................................... Sungai Kakap,
Foto 3 x 4
Foto 3 x 4
......................................................
CATATAN : Mohon di tulis dengan huruf Cetak *) Coret yang tidak perlu
PEMERINTAH KABUPATEN KUBU RAYA
DINAS PENDIDIKAN DAN KEBUDAYAAN Jalan Adisucipto, Km. 15,2
SUNGAI RAYA
==================================================================
BIODATA PENDAMPING OLIMPIADE OLAHRAGA SISWA NASIONAL ( O 2 S N ) SMP TAHUN 2019 KABUPATEN KUBU RAYA 1. N A M A LENGKAP
: ........................................................................................
2. TEMPAT TANGGAL LAHIR
: ........................................................................................
3. ASAL SEKOLAH
: ........................................................................................
4. NIP
: .......................................................................................
5. PENDIDIKAN
: ........................................................................................
6. MENGAJAR BIDANG STUDI
: ........................................................................................
7. ALAMAT SEKOLAH
: ........................................................................................
8. NO TELPON SEKOLAH
: ........................................................................................
9. ALAMAT RUMAH
: ........................................................................................ : ........................................................................................
10. NOMOR HP PENDAMPING
: . ........................................................................................ Sungai Kakap,
Foto 3 x 4
NAMA PENDAMPING
Foto 3 x 4
....................................................
CATATAN : Mohon di tulis dengan huruf Cetak *) Coret yang tidak perlu
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