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FORMULIR PENDAFTARAN PENDIDIKAN KESETARAAN PAKET A, PAKET B, DAN PAKET C
SILAHKAN ISI DATA PRIBADI DENGAN LENGKAP
Q.1
Identitas
*
Nama Depan
Nama Belakang
Q.2
Jenis Kelamin
Laki-laki
Perempuan
Q.3
NISN Dan NIK
*
NISN
NIK
Q.4
Tempat Lahir
Kabupaten Bandung
Kabupaten Bandung Barat
Kabupaten Bekasi
Kabupaten Bogor
Kabupaten Ciamis
Kabupaten Cianjur
Kabupaten Cirebon
Kabupaten Garut
Kabupaten Indramayu
Kabupaten Karawang
Kabupaten Kuningan
Kabupaten Majalengka
Kabupaten Pangandaran
Kabupaten Purwakarta
Kabupaten Subang
Kabupaten Sukabumi
Kabupaten Sumedang
Kabupaten Tasikmalaya
Kota Bandung
Kota Banjar
Kota Bekasi
Kota Bogor
Kota Cimahi
Kota Cirebon
Kota Depok
Kota Sukabumi
Kota Tasikmalaya
Q.5
Tanggal, Bulan, Tahun Lahir
*
Bulan
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
Tanggal
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Tahun
Q.6
Nama Ayah Dan Ibu
*
Ayah
Ibu
Q.7
Sekolah Asal Dan Tahun Lulus
*
Sekolah Asal
Tahun Lulus
Q.8
Alamat
*
Desa
Kecamatan
Kota
Provinsi
Kode Pos
Negara
Abkhazia
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Anonymous Proxy
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Asia/Pacific Region
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europe
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Islamic Republic of Iran
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Occupied Palestinian Territory
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Plurinational State of Bolivia
Poland
Portugal
Puerto Rico
Qatar
Republic of Korea
Republic of South Africa
Republic of the Congo
Reunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Satellite Provider
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Georgia and the South Sandwich Islands
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Swiss Confederation
Syrian Arab Republic
Taiwan
Tajikistan
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United Republic Of Tanzania
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Q.9
Telephon/Handphone
*
Afghanistan (افغانستان)
Albania (Shqipëria)
Algeria (الجزائر)
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia (Հայաստան)
Aruba
Australia
Austria (Österreich)
Azerbaijan (Azərbaycan)
Bahamas
Bahrain (البحرين)
Bangladesh (বাংলাদেশ)
Barbados
Belgium (België)
Belize
Benin (Bénin)
Bermuda
Bhutan (འབྲུག་ཡུལ)
Bolivia
Bosnia and Herzegovina (Bosna i Hercegovina)
Botswana
Brazil (Brasil)
Brunei (Brunei Darussalam)
Bulgaria (България)
Burkina Faso
Burundi (Uburundi)
Cambodia (Kampuchea)
Cameroon (Cameroun)
Canada
Cape Verde (Cabo Verde)
Cayman Islands
Central African Republic (République Centrafricaine)
Chad (Tchad)
Chile
China (中国)
Colombia
Comoros (Comores)
Congo
Congo; Democratic Republic of the
Cook Islands
Costa Rica
Croatia (Hrvatska)
Cuba
Cyprus (Κυπρος)
Czech Republic (Česko)
Côte d'Ivoire
Denmark (Danmark)
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt (مصر)
El Salvador
Equatorial Guinea (Guinea Ecuatorial)
Eritrea (Ertra)
Estonia (Eesti)
Ethiopia (Ityop'iya)
Falkland Islands
Faroe Islands
Fiji
Finland (Suomi)
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia (საქართველო)
Germany (Deutschland)
Ghana
Gibraltar
Greece (Ελλάς)
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea (Guinée)
Guinea-Bissau (Guiné-Bissau)
Guyana
Haiti (Haïti)
Honduras
Hong Kong
Hungary (Magyarország)
Iceland (Ísland)
India
Indonesia
Iran (ایران)
Iraq (العراق)
Ireland
Isle of Man
Israel (ישראל)
Italy (Italia)
Jamaica
Japan
Jersey
Jordan (الاردن)
Kenya
Kuwait (الكويت)
Kyrgyzstan (Кыргызстан)
Laos (ນລາວ)
Latvia (Latvija)
Lebanon (لبنان)
Lesotho
Liberia
Libya (ليبيا)
Liechtenstein
Lithuania (Lietuva)
Luxembourg (Lëtzebuerg)
Macao
Macedonia (Македонија)
Madagascar (Madagasikara)
Malawi
Malaysia
Maldives (ގުޖޭއްރާ ޔާއްރިހޫމްޖ)
Mali
Malta
Martinique
Mauritania (موريتانيا)
Mauritius
Mexico (México)
Moldova
Monaco
Mongolia (Монгол Улс)
Montenegro (Црна Гора)
Montserrat
Morocco (المغرب)
Mozambique (Moçambique)
Namibia
Nauru (Naoero)
Nepal (नेपाल)
Netherlands (Nederland)
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
North Korea (조선)
Norway (Norge)
Oman (عمان)
Pakistan (پاکستان)
Palestinian Territories
Panama (Panamá)
Papua New Guinea
Paraguay
Peru (Perú)
Philippines (Pilipinas)
Poland (Polska)
Portugal
Puerto Rico
Qatar (قطر)
Reunion
Romania (România)
Russia (Россия)
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Saudi Arabia (المملكة العربية السعودية)
Senegal (Sénégal)
Serbia (Србија)
Seychelles
Sierra Leone
Singapore (Singapura)
Slovakia (Slovensko)
Slovenia (Slovenija)
Somalia (Soomaaliya)
South Africa
South Korea (한국)
Spain (España)
Sri Lanka
Sudan (السودان)
Suriname
Swaziland
Sweden (Sverige)
Switzerland (Schweiz)
Syria (سوريا)
Taiwan (台灣)
Tajikistan (Тоҷикистон)
Tanzania
Thailand (ราชอาณาจักรไทย)
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia (تونس)
Turkey (Türkiye)
Turkmenistan (Türkmenistan)
Turks and Caicos Islands
Uganda
Ukraine (Україна)
United Arab Emirates (الإمارات العربيّة المتّحدة)
United Kingdom
United States
Uruguay
Uzbekistan (O'zbekiston)
Vanuatu
Vatican City (Città del Vaticano)
Venezuela
Vietnam (Việt Nam)
Virgin Islands; British
Virgin Islands; U.S.
Wallis and Futuna
Yemen (اليمن)
Zambia
Zimbabwe
Phone/HP
Q.10
Silahkan Pilih Paket
*
A
B
C
Sesuaikan Dengan Tujuan Paket Yang Dikehendaki
Q.11
Silahkan upload File : 1. Ijazah 2. SHUN 3. Kartu Keluarga 4. KTP Orang tua 5. Kartu PIP (bila ada) 6. Akte lahir (bila ada)
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