SELEKSI NASIONAL MASUK PERGURUAN TINGGI NEGERI TAHUN 2017 IDENTITAS DIRI Nama Siswa NISN Nama Sek!a" #Diisi !e" $e%a&a kese"a$a%'(k$e)* Ti%&&i Ba B a(a% Be)a$ Ba Ba(a% BMI
.......................+m .......................k& ....................... BMI , Be)a$ Ba(a% - #Ti%&&i Ba(a%*2
Teka%a% Da)a"
Ss .......... ' ............... Dia .......... ' ................ ................ ' me%i$
De%/$ Na Na(i Is Is$i)a"a$
#Pe%&!i"a$a%* N)ma! B/$a a)%a Si!i%()is'/!i%&'P!/s3 Mi%/s
Se)/me% Os$)/ksi
#a%& 5e)%a" (i(e)i$a*
Apakah anda pernah mengalami sakit dan/atau kelainan fisik untuk hal-hal dibawah ini : a%$/%& Asma Gi%a! Pa)/3Pa)/
E5i!e5si ' Aa% 6e(e)a Fisik Pe)ma%e% Lai%%a #se/$ka%*...................................... Ti(ak A(a
Se$e!a" me!ak/ka% 5eme)iksaa%9 siswa (i%a$aka%Se"a$ Ti(ak Se"a$ A5ai!a a(a 5e)$ima%&a% k"/s/s ............................................................................................................................................. ........................................................................................................................................... Demikia Demikia%% i%:)m i%:)masi asi i%i (isam5 (isam5aik aika% a% (e%&a% (e%&a% see%a see%a)3 )3e%a e%a)% )%aa e)(as e)(asa)k a)ka% a% "asi! "asi! 5eme)iksaa% a%& (i!ak/ka% $e)"a(a5 a%& e)sa%&k/$a%. Peme)iksa9
6a%$/mka% $e)aik a$a/ $e)$i%&&i*
......................................................................... #Nama Le%&ka5 (a% 6a5 I%s$i$/si Peme)iksa* ai"a% 5)es$asi a%& (ia%&&a5
#T/!iska% e%is (a% $i%&ka$a% 5)es$asi a%& (i)ai"*
Isi 5)$:!i a%& $e)+a%$/m #5e%am5i!a%* a(a!a" e%a) se+a)a )isi%i! (ike)aka% (a% (i!aksa%aka% se%(i)i !e" siswa a%& %ama%a $e)+a%$/m (a% e)$a%(a$a%&a% (iawa" i%i. A5ai!a (a!am 5)ses e;a!/asi (a% ;e)i:ikasi (i$em/i a(a%a ke$i(ak//)a% (a%'a$a/ ke+/)a%&a% (a!am e%$/k a5a5/% se+a)a se%&aa9 maka saa e)se(ia mem5e)$a%&&/%&awaka%%a (a% aka% me%e)ima ke5/$/sa% a5a5/% a%& (ie)ika% !e" 5e!aksa%a se!eksi SNMPTN 2017 (i PTN $//a%.
Me%&e$a"/i Ke5a!a Sek!a" SMA'SMK'MA........................................
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#Nama Le%&ka5*
#Nama Le%&ka5 (a% 6a5'S$em5e! Sek!a"*
