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)........................................................................................................

Jakarta, ................................................
KELENGKAPAN BERKAS
Pendaftar / Orang Tua Wali :
 Ijazah Legalisir 2 lbr
 SKHU Legalisir 2 lbr
 Kartu Keluarga
 Pas Photo 2 x 3 = 8 lbr
3 x 4 = 8 lbr _____________________________
 KTP
 NO : ...................

PAKET B
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)........................................................................................................

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 : ...................

PAKET A
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 : ....................................................................................................................

No KK : ...................................................................................................................

Nama Orang Tua : (Ibu)..........................................................................................................

(Ayah)........................................................................................................

Pekerjaan rang Tua : (Ibu)...........................................................................................................

(Ayah)........................................................................................................

Jakarta, ................................................
KELENGKAPAN BERKAS
Pendaftar / Orang Tua :
 Akte Lahir
 Kartu Keluarga
 Pas Photo 2x3=8
 Pas Photo 3x4=8
 KTP (Orang Tua)
_____________________________
*foto copy