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CLASS OF 2019: REGISTRATION FORM

I. Personal Information1. Full Name : ………………………………………………………………

2. Gender : ………………………………………………………………

3. Birthplace, Date of Birth : ………………………………………………………………

4. Current School : ………………………………………………………………

5. Address : ………………………………………………………………

6. Religion : ………………………………………………………………

7. Student’s Phone Number : ………………………………………………………………

8. Email : ………………………………………………………………

II. Parents Information 1. Parent’s Name : Father ……………………… Mother ……………………

2. Parent’s Job : Father ……………………… Mother ……………………

3. Parent’s Phone Number : Father ……………………… Mother ……………………

III. Semester Report Book Score

Subject SemesterI

SemesterII

SemesterIII

Semester IV

SemesterV

Average

Ilmu Pengetahun Alam (IPA)Matematika

Bahasa Inggris

AVERAGE

IV. Achievments/ Awards List:

Achievements Year Rank(1/2/3)

Scale(School/Region/Province/Nat)

....……….…………..… 2019

(…………………………………)

IPTEK - IMTAQ – ETIKA – ESTETIKA - HARMONI

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