Form Biodata Peserta UN Smp-Sma

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SMP/MTs/SMA/MA/SMK

BIODATA PESERTA
PENDATAAN UJIAN NASIONAL SMP/MTs, SMA/MA dan SMK
DINAS PENDIDIKAN KUTAI BARAT TAHUN 2011/2012

Nama

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

NIP

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

Jabatan

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

Pangkat/Gol.

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

Unit Kerja

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

Alamat Sekolah

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

Kode Pos

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

Telp. Sekolah

: ..................................................................... Fax : .................................................

Alamat Rumah

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

Kode Pos

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

Telp. Rumah

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

No. HP

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

(harus diisi)

Alamat email

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

(harus memiliki)

Website

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

Nama Sekolah

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

Nama Kepala Sekolah : ...............................................................................................................................


NIP

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

No. HP (Kepsek)

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

(harus diisi)

........................, ...................................... 2010


Mengetahui,
Kepala Sekolah

Peserta,

.
NIP. ..

.
NIP. ..

Bidang Peningkatan Mutu Pendidikan Dinas Pendidikan Kutai Barat email: [email protected]

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