Biodata Lomba LMCALMCR Tahun 2014

BI ODATA PESERTA
LOMBA MENULI S CERI TA SI SWA 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

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

……………., ……………… 2014
Pasfoto berwarna

Ukuran 4x6

(…………………………………)
Catatan:*) Pilih salah satu

BI ODATA PESERTA
LOMBA MENULI S CERI TA SI SWA 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

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

……………., ……………… 2014
Pasfoto berwarna
Ukuran 4x6

(…………………………………)
Catatan:*) Pilih salah satu