Biodata Peserta LMC 2014

BIODATA PESERTA
LOMBA MENULIS CERITA SISWA SD/MI (LMC-SD/MI)
TAHUN 2014
Isilah dengan huruf Kapital

1. Nama Lengkap

: .....................................................................................................

2. Tempat, Tanggal Lahir

: .....................................................................................................

3. Agama

: .....................................................................................................

4. NISN

: .....................................................................................................

5. Kelas

: .....................................................................................................

6. Jenis Kelamin

: Laki-Laki/Perempuan *)

7. Judul Naskah

: .....................................................................................................

8. Nama Sekolah

: .....................................................................................................

9. Alamat Sekolah
- Jalan

: .....................................................................................................

- Dusun/Desa/Kel/RT/RW *)

: .....................................................................................................

- Kecamatan

: .....................................................................................................

- Kabupaten/Kota

*)

: .....................................................................................................

- Provinsi

: .....................................................................................................

- Kode Pos

: .....................................................................................................

- Telepon Sekolah/Faks

: .....................................................................................................

10. Alamat Rumah/Tempat Tinggal
- Jalan

: .....................................................................................................

- Dusun/Desa/Kel/RT/RW *)

: .....................................................................................................

- Kecamatan

: .....................................................................................................

- Kabupaten/Kota

*)

: .....................................................................................................

- Provinsi

: .....................................................................................................

- Kode Pos

: .....................................................................................................

- Telepon Rumah/Pribadi (HP)

: .....................................................................................................

- Alamat Email

: .....................................................................................................

Pasfoto berwarna
Ukuran 4x6

BIODATA PESERTA
LOMBA MENULIS CERITA SISWA SMP/MTs (LMC-SMP/MTs)
TAHUN 2014
Isilah dengan huruf Kapital

1. Nama Lengkap

: .....................................................................................................

2. Tempat, Tanggal Lahir

: .....................................................................................................

3. Agama

: .....................................................................................................

4. NISN

: .....................................................................................................

5. Kelas

: .....................................................................................................

6. Jenis Kelamin

: Laki-Laki/Perempuan *)

7. Judul Naskah

: .....................................................................................................

8. Nama Sekolah

: .....................................................................................................

9. Alamat Sekolah
- Jalan

: .....................................................................................................

- Dusun/Desa/Kel/RT/RW *)

: .....................................................................................................

- Kecamatan

: .....................................................................................................

- Kabupaten/Kota

*)

: .....................................................................................................

- Provinsi

: .....................................................................................................

- Kode Pos

: .....................................................................................................

- Telepon Sekolah/Faks

: .....................................................................................................

10. Alamat Rumah/Tempat Tinggal
- Jalan

: .....................................................................................................

- Dusun/Desa/Kel/RT/RW *)

: .....................................................................................................

- Kecamatan

: .....................................................................................................

- Kabupaten/Kota

*)

: .....................................................................................................

- Provinsi

: .....................................................................................................

- Kode Pos

: .....................................................................................................

- Telepon Rumah/Pribadi (HP)

: .....................................................................................................

- Alamat Email

: .....................................................................................................

Pasfoto berwarna
Ukuran 4x6