PMB Form - USNB

Registration Form

PROSPECTIVE STUDENT

Full Name

Place of Birth

Date of Birth

Address

Phone Number/Mobile

Gender

Male Female

Email

Religion

KPS Receiver/No

Yes No

NISN

NIK

Diploma Number

Postal Code

Living Type

Transportation

SCHOOL ORIGIN

School Origin Name

School Origin Address

PARENTS' BIODATA

Father Name

Father NIK

Father Place of Birth

Father Date of Birth

Father Religion

Father Education

Father Occupation

Father Address

KPS Receiver/No

Yes No

Father Salary

Father Phone Number/Mobile

Living Type

Mother Name

Mother NIK

Mother Place of Birth

Mother Date of Birth

Mother Religion

Mother Education

Mother Occupation

Mother Address

KPS Receiver/No

Yes No