FORMULIR PPDB 2021

1
FORMULIR PENDAFTARAN

CALON PESERTA DIDIK BARU (PPDB) TAHUN PELAJARAN 2023/2024

SMP NEGERI 1 SATAP MEMPURA

____________________________________________________
2
Nomor Pendaftaran (Biarkan Kosong)Nomor Formulir Pendaftaran biarkan kosong, karena nanti yang mengisi adalah panitia pendaftaran
Diisi panitia pada saat validasi data
3
A. IDENTITAS CALON PESERTA DIDIK
4
Nama Lengkap* This field is required.
tulis nama lengkap sesuai ijazah SMP/MTs
5
Nama Panggilan* This field is required.
tulis nama panggilan sehari-hari
6
Jenis Kelamin* This field is required.
Laki-laki
Perempuan
7
Tempat Lahir* This field is required.
8
Tanggal Lahir* This field is required.
Date
tanggal
bulan
tahun
9
Agama
Islam
Kristen
Katholik
Hindu
Budha
Lainnya
Other
10
Kewarganegaraan* This field is required.
11
Anak Ke berapa* This field is required.
12
Jumlah Saudara Kandung* This field is required.
Jika tidak ada, isi dengan angka 0
13
Jumlah Saudara Tiri
Jika tidak ada, isi dengan angka 0
14
Jumlah Saudara Angkat
Jika tidak ada, isi dengan angka 0
15
Anak Yatim/Yatim Piatu
Yatim
Yatim Piatu
Orang tua lengkap
16
Bahasa Sehari-hari di rumah
17
NISNangka tidak boleh lebih dari 10 digit
isi 10 digit angka NISN
18
NIK* This field is required.angka tidak boleh lebih dari 16 digit
isi 16 digit angka NIK (bisa dilihat di KK)
19
B. KETERANGAN TEMPAT TINGGAL
20
Alamat Lengkap * This field is required.
Kecamatan
Kota/Kabupaten
Provinsi
Kode Pos
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
Tinggal bersama* This field is required.
Orangtua
Saudara
Asrama/Kost
22
No. Telp. / HP
23
E-mail
24
C. KETERANGAN KESEHATAN
25
Golongan Darah
A
B
AB
O
26
Penyakit yang pernah diderita
Contoh: TBC, Cacar, Malaria, dan lain-lain (Jika tidak ada, isi dengan tanda strip (-))
27
Kelainan Jasmani
Jika tidak ada, isi dengan tanda strip (-)
28
Tinggi Badan
Dalam CM
29
Berat Badan
Dalam KG
30
D. DATA AKADEMIK
31
Nama Sekolah Asal SD/MI* This field is required.
32
Alamat Sekolah Asal
33
No. Seri Ijazah SMP/MTs
kosongkan jika ijazah belum terbit
34
No. Seri SHUN SMP/MTs
kosongkan jika SHUN belum terbit
35
Tahun Kelulusan SD/MI
36
Nilai Sekolah / Terakhir (di Surat Keterangan Lulus)
37
Nilai Bahasa Indonesia
38
Nilai Bahasa Inggris
39
Nilai Matematika
40
Nilai IPA (Sains)
41
E. DATA AYAH KANDUNG
42
Nama Ayah* This field is required.
43
Tempat Lahir Ayah
44
Tanggal Lahir Ayah
Date
tanggal
bulan
tahun
45
Agama Ayah
Islam
Kristen
Katholik
Hindu
Budha
Lainnya
46
Kewarganegaraan Ayah
47
Pendidikan Ayah
Please Select
Please Select
Tidak sekolah
Tidak Tamat SD
SD Sederajat
SMP Sederajat
SMA Sederajat
D1/D2/D3 Sederajat
S1 Sederajat
S2 Sederajat
S3 Sederajat
48
Pekerjaan Ayah
49
Penghasilan Ayah
50
Alamat Ayah
Kecamatan
Kota/Kabupaten
Provinsi
Kode Pos
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
51
No. Telp. / HP Ayah
52
Keadaan Ayah
Masih Hidup
Sudah Meninggal
Other
53
Tahun Meninggal Ayah
Hanya diisi jika keadaan Ayah sudah meninggal
54
F. DATA IBU KANDUNG
55
Nama Ibu* This field is required.
56
Tempat Lahir Ibu
57
Tanggal Lahir Ibu
Date
tanggal
bulan
tahun
58
Agama Ibu* This field is required.
Islam
Kristen
Katholik
Hindu
Budha
Lainnya
59
Kewarganegaraan Ibu
60
Pendidikan Ibu
Please Select
Please Select
Tidak sekolah
Tidak Tamat SD
SD Sederajat
SMP Sederajat
SMA Sederajat
D1/D2/D3 Sederajat
S1 Sederajat
S2 Sederajat
S3 Sederajat
61
Pekerjaan Ibu
62
Penghasilan Ibu
63
Alamat Ibu
Kecamatan
Kota/Kabupaten
Provinsi
Kode Pos
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
64
No. Telp. / HP Ibu
65
Keadaan Ibu
Masih Hidup
Sudah Meninggal
66
Tahun Meninggal Ibu
Hanya diisi jika keadaan Ibu sudah meninggal
67
G. DATA WALI/ORANG TUA ANGKAT/ORANG TUA TIRI
68
Nama Wali
69
Tempat Lahir Wali
70
Tanggal Lahir Wali
Date
tanggal
bulan
tahun
71
Agama Wali
Islam
Kristen
Katholik
Hindu
Budha
Lainnya
72
Kewarganegaraan Wali
73
Pendidikan Wali
Please Select
Please Select
Tidak sekolah
Tidak Tamat SD
SD Sederajat
SMP Sederajat
SMA Sederajat
D1/D2/D3 Sederajat
S1 Sederajat
S2 Sederajat
S3 Sederajat
74
Pekerjaan Wali
75
Penghasilan Wali
76
Alamat Wali
Kecamatan
Kota/Kabupaten
Provinsi
Kode Pos
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
77
No. Telp. / HP Wali
78
H. KEGEMARAN SISWA
79
Kesenian
80
Olahraga
81
Kemasyarakatan/Organisasi
82
Lain-lain
83
I. KETERANGAN PERKEMBANGAN SISWA
84
Menerima Beasiswa
85
Tahun
86
Meninggalkan Sekolah
Tuliskan alasan
87
Tanggal Meninggalkan Sekolah
Date
Day
Month
Year
88
J. CATATAN PRESTASI
89
Prestasi yang pernah dicapai
Contoh: Juara 1 Lomba Berenang Tingkat Kabupaten Siak Tahun 2019
90
K. ISIAN PANITIA
91
Bentuk FormulirDiisi oleh panitia
Online
Offline
92
Nama Panitia
Diisi oleh panitia
93
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085385211779 (Ahmad Yusuf)

082391792420 (Mesyanti)

083174422883 (Nino Farida)

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Terimakasih atas kepercayaan anda terhadap SMP Negeri 1 Satap Mempura sebagai pilihan untuk meraih masa depan.
94
Tulis kembali teks di samping* This field is required.
Should be Empty: