blangko bukuinduk siswa

PEMERINTAH KABUPATEN .................
DINAS PENDIDIKAN

SMP NEGERI 1 ....................

BUKU INDUK SISWA
Tahun Pelajaran ..../....

SMP NEGERI 1 ....................
JL. .......................

2017
BUKU INDUK SISWA

A. KETERANGAN PENDIDIKAN
21. Pendidikan Sebelumnya
a. Lulus dari
b. Tanggal dan No. STTB
c. Lamanya Belajar
22. Diterima di Sekolah ini
a. Di Kelas

b. Jurusan
c. Tanggal

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B. KETERANGAN TENTANG AYAH KANDUNG
23. Nama Lengkap
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24. Tempat/Tanggal Lahir
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25. Agama
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26. Kewarganegaraan
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27. Pendidikan Terakhir

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28. Pekerjaan
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29. Penghasilan per Bulan
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30. Alamat Rumah
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31. No. Telp./HP.
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32. Masih Hidup/Meninggal Dunia
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C. KETERANGAN TENTANG IBU KANDUNG
33. Nama Lengkap
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34. Tempat/Tanggal Lahir
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35. Agama
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36. Kewarganegaraan

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37. Pendidikan Terakhir
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38. Pekerjaan
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39. Penghasilan per Bulan
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40. Alamat Rumah
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41. No. Telp./HP.
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42. Masih Hidup/Meninggal Dunia
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D. KETERANGAN TENTANG WALI (BILA SISWA TIDAK IKUT DENGAN ORANG
TUA)

43. Nama Lengkap
44. Tempat/Tanggal Lahir
45. Agama

46. Kewarganegaraan
47. Pendidikan Terakhir
48. Pekerjaan
49. Penghasilan per Bulan
50. Alamat Rumah
51. No. Telp./HP.
52. Hubungan Keluarga dengan Siswa
E. KEGEMARAN SISWA
53. Kesenian
54. Olahraga
55. Kemasyarakatan/Organisasi
56. Lain-Lain

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…………………..,……....... 2016
Mengetahui:
Orang Tua/Wali Siswa,

Siswa yang Bersangkutan,

…………………………………
(Tanda Tangan dan Nama Jelas)

…………………………………
(Tanda Tangan dan Nama Jelas)