Page 2 - Bukom Digital SMA Theresiana 1
P. 2
Pas Photo
3 X 4
IDENTITAS PESERTA DIDIK
Nama : ____________________________________________________________________
Tempat/Tgl. Lahir: ____________________________________________________________________
Alamat : ____________________________________________________________________
Telepon / HP : ____________________________________________________________________
IDENTITAS ORANG TUA / WALI
Nama Ayah : ____________________________________________________________________
Nama Ibu : ____________________________________________________________________
Alamat : ____________________________________________________________________
Telepon/HP : ____________________________________________________________________
Nama Orang Tua Tanda Tangan
1. Ayah : _________________________________
2. Ibu : ________________________________
3. Wali : _________________________________
1
