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DAFTAR ULANG CALON PESERTA DIDIK BARU
DATA PENDUKUNG PPDB SMAN 4 JEMBER TAHUN 2018
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* Indicates required question
Email
*
Your email
NAMA
*
Isilah Nama Sesuai Ijazah
Your answer
Nomer Pendaftaran
*
Isi Sesuai Nomer Pendaftaran. Contoh : 2-18-05-33-XXX-X
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Jenis Kelamin
*
Choose
Laki-Laki
Perempuan
NISN
*
Nomer Induk Siswa Nasional peserta didik 10 digit angka Contoh (000932112344)
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NIK
*
Nomer Induk Kependudukan yang tercantum pada kartu keluarga (KK)
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Asal Sekolah
*
asal sekolah / SMP
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Jumlah UN MP /MTS sederajat
*
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Tempat Lahir
*
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Tanggal Lahir
*
MM
/
DD
/
YYYY
No. Registrasi Akte Lahir
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Agama
*
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Anak Ke-
*
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Jumlah Saudara
*
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Alamat Peserta Didik
*
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RT
*
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RW
*
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Nama Kelurahan
*
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Kecamatan
*
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Kode Pos
*
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Tempat Tinggal
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Choose
Bersama Orang Tua
Wali
Kos
Panti Asuhan
Asrama
Lainnya
Penerima KIP
*
YA
TIDAK
Other:
No. Telpon / HP
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e-Mail
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