Form Pendaftaran Paket C
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NO. FORM : ...........
PC MALAM/REGULER
FORMULIR PENDAFTARAN PKBM NEGERI 17 JAKARTA Nama
: ...................................................................................................................
NIS
: ....................................................................................(diisi oleh Sekolah)
NISN
: ...................................................................................................................
Jenis Kelamin
: ...................................................................................................................
Umur
: .................................................................................................................
Tempat Lahir
: ..................................................................................................................
Tanggal Lahir
: ..................................................................................................................
Agama
: ...................................................................................................................
Kebangsaan
: ...................................................................................................................
Status
: ...................................................................................................................
Alamat Tinggal
: .................................................................................................................. .................................................................................................................
No Telp / HP
: ...................................................................................................................
NIK/ No. KTP
: ....................................................................................................................
Asal Sekolah
: .................................................................................................................
Tahun Lulus
: ..................................................................................................................
No Seri Ijazah
: ...................................................................................................................
No Seri SHUN
: ...................................................................................................................
Nama Orang Tua
: (Ibu).......................................................................................................... (Ayah)........................................................................................................
Pekerjaan rang Tua
: (Ibu)........................................................................................................... (Ayah)........................................................................................................
KELENGKAPAN BERKAS
Ijazah Legalisir 2 lbr SKHU Legalisir 2 lbr Kartu Keluarga Pas Photo 2 x 3 = 8 lbr 3 x 4 = 8 lbr
KTP
Jakarta, ................................................ Pendaftar / Orang Tua Wali :
_____________________________
NO : ...................
FORMULIR PENDAFTARAN PKBM NEGERI 17 JAKARTA
PAKET B MALAM/REGULER
Nama
: ...................................................................................................................
NIS
: ....................................................................................(diisi oleh Sekolah)
NISN
: ...................................................................................................................
Jenis Kelamin
: ...................................................................................................................
Umur
: .................................................................................................................
Tempat Lahir
: ..................................................................................................................
Tanggal Lahir
: ..................................................................................................................
Agama
: ...................................................................................................................
Kebangsaan
: ...................................................................................................................
Status
: ...................................................................................................................
Alamat Tinggal
: .................................................................................................................. .................................................................................................................
No Telp / HP
: ...................................................................................................................
NIK/ No. KTP
: ....................................................................................................................
Asal Sekolah
: .................................................................................................................
Tahun Lulus
: ..................................................................................................................
No Seri Ijazah
: ...................................................................................................................
No Seri SHUN
: ...................................................................................................................
Nama Orang Tua
: (Ibu).......................................................................................................... (Ayah)........................................................................................................
Pekerjaan rang Tua
: (Ibu)........................................................................................................... (Ayah)........................................................................................................ Jakarta, ................................................ Pendaftar / Orang Tua Wali :
KELENGKAPAN BERKAS
Ijazah Legalisir 2 lbr SKHU Legalisir 2 lbr Kartu Keluarga Pas Photo 2 x 3 = 8 lbr 3 x 4 = 8 lbr
KTP/Orang Tua
-----------------------------------------------------------
NO : ...................
FORMULIR PENDAFTARAN PKBM NEGERI 17 JAKARTA
PAKET A MALAM/REGULER
Nama
: ...................................................................................................................
NIS
: ....................................................................................(diisi oleh Sekolah)
NISN
: ...................................................................................................................
Jenis Kelamin
: ...................................................................................................................
Umur
: .................................................................................................................
Tempat Lahir
: ..................................................................................................................
Tanggal Lahir
: ..................................................................................................................
Agama
: ...................................................................................................................
Kebangsaan
: ...................................................................................................................
Status
: ...................................................................................................................
Alamat Tinggal
: .................................................................................................................. .................................................................................................................
No Telp / HP
: ...................................................................................................................
NIK/ No. KTP
: ....................................................................................................................
No KK
: ...................................................................................................................
Nama Orang Tua
: (Ibu).......................................................................................................... (Ayah)........................................................................................................
Pekerjaan rang Tua
: (Ibu)........................................................................................................... (Ayah)........................................................................................................
KELENGKAPAN BERKAS Akte Lahir Kartu Keluarga Pas Photo 2x3=8 Pas Photo 3x4=8 KTP (Orang Tua) *foto copy
Jakarta, ................................................ Pendaftar / Orang Tua :
_____________________________
PC MALAM/REGULER
FORMULIR PENDAFTARAN PKBM NEGERI 17 JAKARTA Nama
: ...................................................................................................................
NIS
: ....................................................................................(diisi oleh Sekolah)
NISN
: ...................................................................................................................
Jenis Kelamin
: ...................................................................................................................
Umur
: .................................................................................................................
Tempat Lahir
: ..................................................................................................................
Tanggal Lahir
: ..................................................................................................................
Agama
: ...................................................................................................................
Kebangsaan
: ...................................................................................................................
Status
: ...................................................................................................................
Alamat Tinggal
: .................................................................................................................. .................................................................................................................
No Telp / HP
: ...................................................................................................................
NIK/ No. KTP
: ....................................................................................................................
Asal Sekolah
: .................................................................................................................
Tahun Lulus
: ..................................................................................................................
No Seri Ijazah
: ...................................................................................................................
No Seri SHUN
: ...................................................................................................................
Nama Orang Tua
: (Ibu).......................................................................................................... (Ayah)........................................................................................................
Pekerjaan rang Tua
: (Ibu)........................................................................................................... (Ayah)........................................................................................................
KELENGKAPAN BERKAS
Ijazah Legalisir 2 lbr SKHU Legalisir 2 lbr Kartu Keluarga Pas Photo 2 x 3 = 8 lbr 3 x 4 = 8 lbr
KTP
Jakarta, ................................................ Pendaftar / Orang Tua Wali :
_____________________________
NO : ...................
FORMULIR PENDAFTARAN PKBM NEGERI 17 JAKARTA
PAKET B MALAM/REGULER
Nama
: ...................................................................................................................
NIS
: ....................................................................................(diisi oleh Sekolah)
NISN
: ...................................................................................................................
Jenis Kelamin
: ...................................................................................................................
Umur
: .................................................................................................................
Tempat Lahir
: ..................................................................................................................
Tanggal Lahir
: ..................................................................................................................
Agama
: ...................................................................................................................
Kebangsaan
: ...................................................................................................................
Status
: ...................................................................................................................
Alamat Tinggal
: .................................................................................................................. .................................................................................................................
No Telp / HP
: ...................................................................................................................
NIK/ No. KTP
: ....................................................................................................................
Asal Sekolah
: .................................................................................................................
Tahun Lulus
: ..................................................................................................................
No Seri Ijazah
: ...................................................................................................................
No Seri SHUN
: ...................................................................................................................
Nama Orang Tua
: (Ibu).......................................................................................................... (Ayah)........................................................................................................
Pekerjaan rang Tua
: (Ibu)........................................................................................................... (Ayah)........................................................................................................ Jakarta, ................................................ Pendaftar / Orang Tua Wali :
KELENGKAPAN BERKAS
Ijazah Legalisir 2 lbr SKHU Legalisir 2 lbr Kartu Keluarga Pas Photo 2 x 3 = 8 lbr 3 x 4 = 8 lbr
KTP/Orang Tua
-----------------------------------------------------------
NO : ...................
FORMULIR PENDAFTARAN PKBM NEGERI 17 JAKARTA
PAKET A MALAM/REGULER
Nama
: ...................................................................................................................
NIS
: ....................................................................................(diisi oleh Sekolah)
NISN
: ...................................................................................................................
Jenis Kelamin
: ...................................................................................................................
Umur
: .................................................................................................................
Tempat Lahir
: ..................................................................................................................
Tanggal Lahir
: ..................................................................................................................
Agama
: ...................................................................................................................
Kebangsaan
: ...................................................................................................................
Status
: ...................................................................................................................
Alamat Tinggal
: .................................................................................................................. .................................................................................................................
No Telp / HP
: ...................................................................................................................
NIK/ No. KTP
: ....................................................................................................................
No KK
: ...................................................................................................................
Nama Orang Tua
: (Ibu).......................................................................................................... (Ayah)........................................................................................................
Pekerjaan rang Tua
: (Ibu)........................................................................................................... (Ayah)........................................................................................................
KELENGKAPAN BERKAS Akte Lahir Kartu Keluarga Pas Photo 2x3=8 Pas Photo 3x4=8 KTP (Orang Tua) *foto copy
Jakarta, ................................................ Pendaftar / Orang Tua :
_____________________________
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