FORMULIR PSB 2017 - SEKOLAH

KEMENTERIAN AGAMA REPUBLIK INDONESIA
INSTITUT AGAMA ISLAM NEGERI
ANTASARI BANJARMASIN
Jl. Jenderal Ahmad Yani Km. 4,5 Banjarmasin 70235
Telepon (0511) 3252829, Faksimili (0511) 3254344, Website : www.iain-antasari.ac.id

FORMULIR PENDAFTARAN SEKOLAH
1. Nama Sekolah

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2. NPSN

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3. Jenis Sekolah

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.......................... (MAN/MAS/SMAN/SMAS/SMKN/SMKS/Ponpes)

4. Akreditasi Sekolah

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5. Alamat Sekolah

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Desa / Kelurahan : ............................................................................
Kecamatan : ......................................................................................
Kota / Kabupaten : .............................................................................

6. Nomor Telepon

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7. Nomor Faksimile

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8. Email Sekolah

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9. Website Sekolah

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10. Nama Kepala Sekolah

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11. Nomor HP Kepala Sekolah :

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12. Jumlah Siswa Kelas XII

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13. Jumlah Siswa Berdasarkan Jurusan Kelas XII :

IPA

Keagamaan

IPS

Kejuruan

Bahasa
Kepala Sekolah,

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NIP.