PEMERINTAH KABUPATEN BULELENG DINAS PENDIDIKAN

SMA NEGERI 4 SINGARAJA JALAN MELATI SINGARAJA TELEPON (0362)22845 FAX. (0362)32809 http://sma4singaraja.net email : [email protected]

FORMULIR PENDAFTARAN CALON SISWA BARU No. Formulir : Jalur : Ditentukan oleh sekolah sendiri) Tulislah identitas diri Anda pada kolom isian yang tersedia sesuai dengan data-data dalam ijazah terakhir Tulis nomor pada kolom yang tersedia

No Peserta Ujian Nasional

:

Tahun Kelulusan

:

Nama Lengkap

:

Usia

:

Tempat / Tanggal Lahir

:

Jenis Kelamin *)

:

Alamat Rumah

:

Kota :

Asal Sekolah

:

Kota :

Nomer Telepon

:

Tahun

Laki-laki

/ Perempuan.

-

-

(dd-mm-yyyy)

*) Beri tanda (X)

DATA NILAI Tulislah data-data nilai untuk setiap mata pelajaran yang diminta sesuai dengan dokumen SKHUN

Matematika

:

Bahasa Inggris

:

IPA / SAINS

:

Bahasa Indonesia

:

, , , ,

TOTAL SKHUN

:

,

PILIHAN SEKOLAH Tulislah nama sekolah pada kolom yang tersedia sesuai prioritas pilihan sekolah yang diinginkan

Pilihan ke-1

: SMA/MA

Pilihan ke-2

: SMA/MA

Pilihan ke-3

: SMA/MA

Singaraja,

Juni 2016

Petugas Pendaftaran,

Mengetahui Orang Tua/Wali Siswa,

Siswa Pendaftar,

(_________________________)

(_________________________)

(_________________________)

PSB-Formulir Pendaftaran SMAN 4 Singaraja UN.pdf

TELEPON (0362)22845 FAX. (0362)32809. http://sma4singaraja.net email : [email protected]. FORMULIR PENDAFTARAN. CALON SISWA BARU.

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