2020

TABLE OF CONTENT

TABLE OF CONTENT....................................................................................................................................... 1
PREFACE........................................................................................................................................................ 2
CHAPTER 1..................................................................................................................................................... 4
A. LERNING ACTIVITY 1........................................................................................................................................4
1. The goals of Learning Activity 1.................................................................................................................4
2. Materials....................................................................................................................................................4
3. Task............................................................................................................................................................5
4. Exercises.....................................................................................................................................................6
B. LEARNING ACTIVITY 2....................................................................................................................................8
1. The Goals of Learning Activity 1................................................................................................................8
2. Materials....................................................................................................................................................8
3. Task............................................................................................................................................................8
5. Exercise......................................................................................................................................................9
EVALUATION............................................................................................................................................... 10

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 1

 PREFACE

The government, education ministry sets out the curriculum 2013 to increase the quality
of education in Indonesia. In learning activity, all the teaschers should aply this curriculum.
But there is still not realiable to reach the target. So, it needs curriculum 2013 (Revision).
Learning activity in the classroom needs the various kinds of learning models, such as
Discovery Learning, Project Based Learning, Problem Solved Learning, etc. To create this
learning activity within those models, the teacher should make an English module creatively.
These models are hoped to reach the target that the education ministry plans. Making
module creatively by the teachers, the students will understand the materials and joining the
class easily.
Especially the students of X grade will get the final examination to pass it and go to the
XI grade.
Study this general guide to study this module :
1. Studying this module both individually and group.
2. Understanding the materials by doing the tasks, exercises and ecaluation.
3. You will get the score after you finish doing the tasks, exercises, evaluation in
speaking,reading and writing. But for listening you will get the difference module and
different materials in language of laboratory. (TOEIC & TOEFL).
4. Filling the reflection to know your ability by yourself.
5. To elaborate your knowledge, you can study the materials in newspaper, magazine, BSE and
internet.

In this module you will study the basic competency that stated in the curiculum 2013:
KD. 3.1. Membedakan fungsi social, struktur teks dan unsur kebahasaan beberapa teks khusus
dalam bentuk formulir isian yg digunakan di perusahaan / bank/ instansi lain, dengan
member dan meminta informasi terkait jati diri dan informasi yang relevan, sesuai
denagan konteks penggunaannya.
4.1.Menangkap makna secara kontekstual terkait fungsi social, struktur teks, dan unsur
kebahasaan teks khusus dalm bentuk formulir isian yang digunakan di perusahaan/
bank/instansi lain, terkait jati diri dan informasi yang relevan..

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 2

Study this concept to understand the materials and you can get the best score.

MIND MAPPING

To get successfull in understanding the materials, read and pay attention the general
guide to study the learning activity 1 and 2.

GENERAL GUIDE :
1. Study and understandthe materials ofActivity 1 and 2 !
2. Do exercises, task in the provided place!
3. You ca study and do “ exercises and tasks”,if you understand, you can continue
to the evaluation about Filling The Forms.
4. Do Evaluation by choosing the true option individually!
5. Do the exercises and task with your group to practice writing and speaking!

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 3

 CHAPTER 1

A. Learning Activity 1

1. The goals of Learning Activity 1

 Explaining the language feature “Filling The Forms.”
 Explaining the function and the generic structure “Filling The Forms.”
 Comparing the kinds of forms by answering the questions.”

2. Materials

Before having the material in this section. Have a look at the picture /video
Below !

Answer the following questions.

What do you have in the picture?

_______________________________________________________________________

Have you ever seen the activity?

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 4

 Where do you usually see the activity?
_______________________________________________________________________

What kinds of activities do you usually see?

From the picture/video above, what information do you get?

Let’s Study

Read and study the pattern carefully!

DEFINITION

A form is a document (Printed or electronic) with spaces in which we can write or enter
data
To Give information in details about the personal identity
SOCIAL FUNCTION: giving information

LANGUAGE FEATURES
GENERIC STRUCTURE Exact noun
Identity Adverb phrase and adverb clause
Clear instructions about information to be supplied
Verbs
Uniformity (for special purpose) Aking & Response
Signature vocabularies

``

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 The Kinds of Form (The Examples of Form)
1.
STAR
STAR ACT INTERVIEW FORM ACT

NAME : AGE :

1. Why do you like singing?

2. Why would you like to win the
competition?
3. Would you like to be famous one
day?
4. Do you like dancing?
5. What music do you like listening
to?
6. Which famous singer would you
like to be?
7. Would you like to star in your
own TV programme?
8. What would you like to do with
the prize, money?
9. Why do want to be a singer?
10. Which do you want to be a singer
or a movie star?

2.

3.

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 6

 STAFF 3x4
UNLIMITED

Name : ERIC HUESTON

Age : .........................
Nationalty : AMERICAN
Marital Status : ........................
Qualification : Degree in ............ UCLA, 2001
Work Experience : * 2002 – 2006 Head Barman, Ai’s Bar, Venich Beach,
California
* 2006 - 2010 assistant Manager, ....... (place)

Skills : Working knowledge of word, Wxcel and other computer

programs
Personal Interests : ................., reading
Job Suitability : I’ve got a year’management experience, and I am well
organised and ..................
References : Andrew Cole, Professor of Hotel management, UCLA

Summary

REMEMBER !
From Three kinds of form we must pay attention :
1. The definition of form is a document (Printed or
electronic) with spces in which we can write or enter
data.
2. The function of form is to give information in detais
about the personal identity.
3. The Generic structure is identity, clear instructions
about informations to be suppied and uniformity (for
special).

3.Task

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 7

 Let’s study the vocabularies to check
your understanding the material
before doing the the task

TASK 1. Read and learn some vocabularies that are used in this section. Then
complete the definition !

WORD DEFINITION

WITHDRAW

SAVE

ACCOUNTING

PURCHASE
FORM

DEPOSIT SLIP

RESERVATIO
N FORM

MEDICAL
FORM

WITHRAWAL
SLIP

TELLER

PAYMENT

TASK 2. To check your understanding on the words, fill in the blanks with the
Most appropriate words you have just learnt.

1. You can take a ..... before you see the doctor in the hospital.
2. Would you please take a ..... before you go to the teller to get your money?
3. Have you got a ..... ? Yes, I‘ve got it. I will have stayed here for three nights
4. The manager : Have you finished your finance report?
The secretary : Yes, Sir. I’ve finished and checked it twice. So, It won’t be double ....
5. He hasn’t ..... completed two half marathons.
6. She would be placed as a …. next week
7. I became interested to save my money to the bank so I want to fill a ....
8. Mother : Do’t forget to .... a little money for your future, Alice!
Alice : Yes, Mom. I’ll do it every month.

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 8

9. Director : Have you checked the ... before you send to Mr. Abraham’s company?
Manager : Not yet. I will checked it now and I will give you before I go to
Mr. Abraham’s office
10. Teller : Good morning, Sir. What can I do for you?
Man : Good morning. I’d like to ..... some money.
Teller : May I look your ID card and How much ?
Man : Rp. 5.000.000

Let’s check your understanding

about Fill
the present
out the perfect
Form and past
simpleTense

4. Exercises

Look at the information given, then complete these forms correctly and make a
conversation with a partner’s !

1. Form A

Reservation Form
Bali Beach Hotel
Name : (1..........................................................................................)
Address : (2...........................................................................................)
Ocuupation : (3...........................................................................................)
Married/single : (4...........................................................................................)
Type of Room : (5)
Single room Double rooms

Suit room Extra room

(6................) : 3 days
(7................) : 13th - 16th August
(8................) : Rp. 1.500.000/night
(9................) : Credit card
(10..............) : (031) .........................

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 2. Form B

Purchase Form
Textile Company

Name :
Order No. : (1) .....................................................................................
(2) .............: 7899
(3) .............: (4) ......................................................................................
Name of Goods : (6) .....................................................................................
(7) .....................................................................................
(8) .....................................................................................
(9)............ : 5 Oct. 2017
(10) ......... : 10%
(11) ......... : US $ 5.50
Delivery charge : (12) ..................................................................................
Total Amount : (13) ..................................................................................

3. Form C

Reservation Form

Gardenia Village

(1) .............. : ............................................................................................

(2) .............. : ............................................................................................
(3) .............. : ............................................................................................
(4) .............. : ............................................................................................
(5) .............. : ............................................................................................
(6) .............. : ............................................................................................
(7) .............. : ............................................................................................
(8) ............. : .............................................................................................

Reflection At the end of this session, ask yourself the followimg

questions to know how
SMA NEGERI 1 GRESIK effective
ENGLISH your learning
LITERATURE X prosses is. 10
 NO Questions Yes No
1. Do you know the definition of a form?
2. Do you know how many kinds of form?
3. Do you know how to fill a form?
4. Do you know how the function of form?
5. Do you know the linguistic features of a form?

After understanding this materials, you can continue to the the learning activity 2

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 11

 B. Learning Activity 2

1. The Goals of Learning Activity 1

 Making a dialog about filling a form !
 Performing a dialog about filling a form !

2. The Materials

Asking an information Giving an information

1. What is your name? *my name is ...

2. Where is your address? *Jalan Panglima Sudirman ....
3. What is your telephone
*03139578487
number?
4. Can you give your identity
*.here it is
card, please?
5. Will you give your
*Ok.
signature here, please?

Let’study and analyze this form to get the social function, text
Examples :
organisation and the language features.

Read the information about two potential contestants for Indoneasian Idol below
carefully

Name : Sheana Miles

Name : Gary Thomas Age : 29
Age : 38 Profession : Chef at Italian restaurant
Profession : Hairdresser Interest : Rock music, painting, visiting
Interest : Dance, music, going to the art galleries, political
gym, celebrity gossip, soap discussions
operas Dislike : Gossip magazines, people
Dislike : Intectual people, Italian food concerned with they look
Ambition : would like to be David Ambition : would like to buy a
Beckham’s hairdresser restaurant

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Answer the questions based on the above informations!
1. What do the two informations tell us about?
_______________________________________________________________________
_______________________________________________________________________

2. Why did Gary fill the form?

_______________________________________________________________________
_______________________________________________________________________

3. Why did Sheana fill the form?

_______________________________________________________________________
_______________________________________________________________________

4. What skill has she had?

_______________________________________________________________________
_______________________________________________________________________

5. What would She want to be?

_______________________________________________________________________
_______________________________________________________________________

6. What would Gary want to be?

_______________________________________________________________________
_______________________________________________________________________

7. Analyze the content of the form !

_______________________________________________________________________
_______________________________________________________________________

8. Write the activities that Gary like?

_______________________________________________________________________
_______________________________________________________________________

9. Write the activities that Sheana like?

_______________________________________________________________________
______________________________________________________________________

10. What activity do Gary and Sheana like ?

_______________________________________________________________________
______________________________________________________________________

Summary

REMEMBER !
From the dialog we know that :
1. They are customers and an employee.
2. Prepare ID Card and fill the form correctly.

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 13

 3. Task

TASK 1.
Let’s do the task to understand your knowledge by making an
interview

1. Writing assignment
With your partner read and study this form !. Make an interview to a famous person !

Name :
Age :
Nationality :
Marital status :
Qualification :
Work Experience :
Skills :
Personal Interest :
Job suitability :
References :

2. Speaking assignment
Present your interview that you have made with your partner!
Let’s check your understanding
about the material you have got

TASK 2. Swap roles. You are now the organiser of a university open day. Prepare
information about the folowing questions and clues !

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 14

 Questions clue Answer

1. Where do you University name and

study? location

2. How --------------- Student population

3. What -------------- Most popular

courses and subjects
4. When ------------- Special open day
events
5. What -------------- Extra-curricular
activities
6. How Much ------- Tuitition fees

7. What -------------- Tours and talks

4. Exercise
Fill out this form based on your own identty correctly!

Answer these Questions based on the above form!

1. What do you call this kind of form?
2. What institution issued this form?
3. Why do you have to fill out this form?
4. What would happen if you didn’t fill out this form?
5. How much do you save your money?
6. When do you want to save your money?

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 After you finished doing the activities 1 and 2, try
to do the evaluation

EVALUATION

A. Multiple choice

Choose the correct answer by crossing (X) a,b,c,d, or e !

This below form is for number 1 to 3

Donald Beker
707 kaliurang Street
East Java – Indonesia

Jogyakarta , 17 January 2019

Pay to the order of $ 75 ( Seventy five dollars)

Bank Negara Indonesia (BNI) 46

Jalan Veteran Gresik – Jawa Timur

MEMO Signature
For buying 5 Sarungs and
----------------------------------------
2 T-shirts Donald B
--------------------------------------- (--------------------------)

1. What is the purpose of the above form ?

a. To give information about Donald payment
b. To explain about Donald payment
c. To announce the readers about Donald payment
d. To amuse the readers about Donald payment
e. To give information about Donald’s activities

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 16

 2. Why did Donald make this form?
a. He was a lucky man
b. He bought 5 Sarungs and 2 T-shirts
c. He transfered the money for paying sarung and T-shirts
d. He took the money at Bank Negara Indonesia
e. He saved the money at Bank Negara Indonesia

3. How did Donald pay his sarungs and T-shirts?

a. By paying at Bank National Indonesia (BNI) 46
b. By paying at Bank Niaga Indonesia (BNI) 46
c. By paying at Bank Niagara Indonesia (BNI) 46
d. By paying at Bank Negara Indonesia (BNI) 46
e. By paying at Bank Nugraha Indonesia (BNI) 46

This text is for number 4 to 6 !

4. Why did Mr. Juan fill this form?

a. Because he got this form from COL Financial group, Inc
b. Because he wanted to pay his study
c. Because he studied at business administration degree
d. Because he went to Philipine
e. Because he wanted to pay his order

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 17

 5. How can Mr. Juan pay ?
a. Rupiahs
b. Rupee
c. Bath
d. Peso
e. Pounsterling
6. What kind of form is it?
a. Deposit form
b. Purchase form
c. Medical form
d. Reservation form
e. Withdrawal slip

This text is for number 7-10 !

Dear Sir,

I read about your hotel in an advertisement in “People” magazine. The most

attractivething to me is that I want to spend this year’s vacation at a seaside area and
get involved in some water-sports activities, because ypur hotel has a good sea with
plenty of water-sports activities, like diving, surfing, jet skiing and water football,
which is what I’m most interested in.

This is to inquire about the availability of accomodation in your hotel in August this
year. My wife, my son and I are scheduled to visit Bali for 3 days from 13th to 16th
August and wish to stay at your hotel. I am looking for a well-furnished doubled-
deluxe balcony room suite, bath attached.

Please, let me know your tariff and availability of dates I have mentioned and a cost
comparison with other weekdays.

I would appreciate if you would call me regarding this resevation as soon as you
can.

I look forward to hearing from you soon.

Yours faithfully,

Hadi Ibrahim

7. What does the passage inform you about?

a. It’s about Hadi’s activities
b. It’s about Hadi’s schedule to visit Bali for 3 days
c. It’s about Hadi’s ambitions
d. It’s about Hadi’s travelling arround Bali
e. It’s about Hadi’s planning to stay in a hotel

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 18

 8. How long does Mr. Hadi want to make reservation a room ?
a. Three days
b. Four days
c. Five days
d. Six days
e. A week
9. Why does she want to book a room in that hotel?
a. Bacause it has a well-furnished double-deluxe balcony room suite, bath
attached
b. Because it has a good sea view with plenty of water-sports activities
c. Because it has jet skiing and water football
d. Because he likes diving and surfing
e. Because he wants to spend this year’s vacation at hotel in Bali
10. Where does Mr. Hadi get this advertisement from?
a. Newspaper
b. Television
c. Magazine
d. Friends
e. Hotel

B. Essay

Read this form and answer the questions based on the folowing form!

1. What do you call this kind of form?

2. What institution issued this form?
3. Why did you have to fill out this form?
4. What would happen if you didn’t fill out this form?
5. What is the function of this form?

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 19

 RFLECTION

At the end of this session, ask yourself the followimg questions

to know how effective your learning prosses is

Ye
No Questions No
s
1 Do you know how to make questions and answer about filling
the form orally?
2 Do you know how to fill the form in written ?
3. Do you know how the linguistic feature to write a form?
4 Do you know how to write a dialog about filling a form?
5 Do you know to perform a dialog about filling a form?

If your answer is “No” to any one of these questions, open and study your english book.
Don’t give up! see your teacher and discuss with her/him on how to fill the forms. But if
your answer is “Yes” It means you can understand the materials of Filling forms.

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 20

 BIBLIOGRAPHY

Theresia Sudarwati & Eudia Grace, Jakarta.2017 (Revisi). Pathway to English Untuk SMA
kelas X : Penerbit Erlangga.(Anggota IKAPI): Jakarta .
Lynda edwards.2013.English elevator International 1: Student’s Book. Indonesia:PT ASTA
Ilmu Sukses.
Lynda edwards.2013.English elevator International 2: Student’s Book. Indonesia:PT ASTA
Ilmu Sukses
Herbert Putcha dkk,Singgapore 2013(Second Edition).English in Mind Work book 4:
Cambridge University Press

SMA NEGERI 1 GRESIK ENGLISH LITERATURE X 21