PANITIA

LOMBA KOMPETENSI SISWA (LKS) SMK XX

TINGKAT PROPINSI JAWA TIMUR TAHUN 2012

SMK NEGERI 1 MAGETAN

Jl. Kartini No. 06 Magetan 63314 (0351) 895094 Fax.(0351) 895094

Website : http://www.smkn1-magetan.sch.id Email : smkn1_magetan@yahoo.co.id

BIDANG LOMBA

.....................................................

1. Nama Peserta

........................................................................

2. Jenis Kelamin

Laki-laki / Perempuan *)

3. NIS

........................................................................

4. Tempat/Tanggal Lahir

........................................................................

5. Agama

........................................................................

6. Program Keahlian

................................................. Kelas .............

7. Asal Sekolah

SMK .................................................................

8. Alamat Sekolah

Jl. ....................................................................
........................................................................
......................................................................

..

Tlp. (.......) .................. Fax.

(.......) ..................

9. Alamat Rumah

Jl. ....................................................................
........................................................................
Kab./Kota*) ......................................................
Provinsi ...........................................................

Pas
Photo
3X4

Mengetahui;

Telp. (.........) .........................., .......................

HP. ........................................................

....................., .................... 2012

Kepala Sekolah
SMK ............................................

Peserta,

.......................................

...................................

NIP.
Catatan :

- Diisi dengan huruf capital/diketik

PANITIA
LOMBA KOMPETENSI SISWA (LKS) SMK XX
TINGKAT PROPINSI JAWA TIMUR TAHUN 2012

SMK NEGERI 1 MAGETAN

Jl. Kartini No. 06 Magetan 63314 (0351) 895094 Fax.(0351) 895094

Website : http://www.smkn1-magetan.sch.id Email : smkn1_magetan@yahoo.co.id

- Hanya menyertakan foto copy raport

- Peserta bukan pemenang LKS 2011
- *) coret yang tidak perlu

PANITIA
LOMBA KOMPETENSI SISWA (LKS) SMK XX
TINGKAT PROPINSI JAWA TIMUR TAHUN 2012

SMK NEGERI 1 MAGETAN

Jl. Kartini No. 06 Magetan 63314 (0351) 895094 Fax.(0351) 895094

Website : http://www.smkn1-magetan.sch.id Email : smkn1_magetan@yahoo.co.id

BIDANG LOMBA

.....................................................

1. Nama (Lengkap dengan gelar)

........................................................................

2. Jenis Kelamin

Laki-laki / Perempuan *)

3. NIP

........................................................................

4. Tempat/Tanggal Lahir

........................................................................

5. Agama

........................................................................

6. Jabatan Dinas

........................................................................

7. Unit Kerja

SMK .................................................................

8. Alamat Unit Kerja

Jl. ....................................................................
........................................................................
......................................................................

..

............................................................

............

Tlp. (.......) .................. Fax.

(.......) ..................
Alamat Rumah

Jl. ....................................................................
........................................................................
Kab./Kota*) ......................................................
Provinsi ...........................................................

Pas
Photo
3X4

Mengetahui;

Telp. (.........) .........................., .......................

HP. ........................................................

....................., .................... 2012

Kepala Sekolah
SMK ............................................

Pembimbing,

.......................................

...................................

NIP.
Catatan :

- Diisi dengan huruf kapital/diketik

PANITIA
LOMBA KOMPETENSI SISWA (LKS) SMK XX
TINGKAT PROPINSI JAWA TIMUR TAHUN 2012

SMK NEGERI 1 MAGETAN

Jl. Kartini No. 06 Magetan 63314 (0351) 895094 Fax.(0351) 895094

Website : http://www.smkn1-magetan.sch.id Email : smkn1_magetan@yahoo.co.id

- *) coret yang tidak perlu

KABUPATEN/KOTA

.....................................................

1. Nama (Lengkap dengan gelar)

........................................................................

2. Jenis Kelamin

Laki-laki / Perempuan *)

3. NIP

........................................................................

4. Tempat/Tanggal Lahir

........................................................................

5. Agama

........................................................................

6. Jabatan Dinas

........................................................................

7. Unit Kerja

................................................................

8. Alamat Unit Kerja

Jl. ....................................................................
........................................................................
......................................................................

..

............................................................

............

Tlp. (.......) .................. Fax.

(.......) ..................
Alamat Rumah

Jl. ....................................................................
........................................................................
Kab./Kota*) ......................................................
Provinsi ...........................................................

Pas
Photo
3X4

Telp. (.........) .........................., .......................

HP. ........................................................

....................., .................... 2012

Ketua Kontingen,

...................................
NIP.

PANITIA
LOMBA KOMPETENSI SISWA (LKS) SMK XX
TINGKAT PROPINSI JAWA TIMUR TAHUN 2012

SMK NEGERI 1 MAGETAN

Jl. Kartini No. 06 Magetan 63314 (0351) 895094 Fax.(0351) 895094

Website : http://www.smkn1-magetan.sch.id Email : smkn1_magetan@yahoo.co.id

Catatan :

- Diisi dengan huruf kapital/diketik

- *) coret yang tidak perlu