Departement of Education

Form B152
Republik Indonesia

Name : Fabiola Nafisah Harnida Male / Female

Place/ date birth : Karanganyar 11/27/2005
Address : Plampang Rt 02 Rt 08 Rejosari Polokarto Sukoharjo

Father

Name : Dwi Haryanto Age : 45

Occupation :Private Employees

Mother
Name : Heni Faridah Age : 38
Occupations : Civil Cervant

For office use School : SMAN JUMAPOLO

No…......... Year : 1 /2 /3 Semester 1 /2

Date :….....
Comments: Why do you want to transfer here ?

Because I'm following my parents

Polokarto,16ʵʰ July 2021

Person in charge : Father student,

….........

Sig :…... (Dwi Haryanto ) ( Fabiola Nafisah Harnida )