SIJIL BERHENTI SEKOLAH

1. Nama Penuh: ...............................................................................................................................

2. Nama Bapa/ Penjaga: ..................................................................................................................
3. No. KP: ........................................................... 4. No. Sijil Lahir: ........................................
4. Tarikh Lahir: ................................................... 6. Tempat Lahir: .........................................
7. Bil. Masuk Sekolah: ........................................ 8. Tarikh Masuk Sekolah: ...........................
9. Ting. Mula Masuk: .......................................... 10. Ting. Tertinggi yang Akhir: ....................
.......................................................................... ................................................................
(Tulis dengan perkataan) (Tulis dengan perkataan)

11. Tahun Peperiksaan: (a) PMR: ............................. Pangkat .............................................

(b) SMA: ............................ Pangkat .............................................
(c) SPM: ............................. Pangkat .............................................
12. Kedatangan: ................................................................................................................................
13. Nama dan Alamat Sekolah Dahulu: ............................................................................................
............................................................................................
14. Kokurikulum
(a) Jawatan Khas: .......................................................................................................................
(b) Pasukan Beruniform: ............................................................................................................
(i) Jawatan Disandang: ..................................................................
(ii) Pencapaian: ..............................................................................
(c) Persatuan: ..............................................................................................................................
(i) Jawatan Disandang: ..................................................................
(ii) Pencapaian: ..............................................................................
(d) Sukan: ...................................................................................................................................
(i) Jawatan Disandang: .................................................................
(ii) Aktiviti: ...................................................................................
(iii) Pencapaian: .............................................................................
(e) Olahraga: ...............................................................................................................................
(i) Jawatan Disandang: .................................................................
(ii) Aktiviti: ....................................................................................
(iii) Pencapaian: .............................................................................
15. Kelakuan: ..................................................................................................................................
16. Tarikh Berhenti Sekolah: ..........................................................................................................
17. Sebab Berhenti: .........................................................................................................................
18. Catatan Tambahan: ...................................................................................................................
...................................................................................................................................................

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(Tandatangan Murid) (Pengetua)

Tarikh: Tarikh: