Nomor Identitas (Indentity Number) - (ID Card/Family Card/Passport)*
ID Card
Family Card
Passport

Nomor Identitas (Indentity Number) - (ID Card/Family Card/Passport)*

Nama Lengkap (Full Name)*

Tempat Lahir (Place Of Birth)*

Tanggal Lahir (Date Of Birth)*

Jenis Kelamin (Gender)*
Pria (Male) Wanita (female)

Agama (Religion)* Islam Christian Hindu Budha Others

Alamat Rumah (Home Address) *

Telpon Rumah (Phone Number)

Handphone (Mobile Phone)*

Alamat Email (Email Address)*

Kata Sandi (Password)*

Hobi (Hobby)*

Asal Sekolah (Origin Of High School)*

Provinsi Sekolah ( School Province )

Tahun Masuk Sekolah (Year Of Entering High School)*

Tahun Kelulusan (Year Graduated From High School)*

Jenis SMU (Type High School)*
SMU (Public High School)
SMK (Vocational School)
Lainnya (Other)

Jurusan Sekolah (School Major)*

Status SMU (High School Status)*
Negeri (Public)
Swasta (Private)
Luar Negeri (Overseas)

Nama Ayah Kandung (Name Of Biologic Father)*

Nomor Telepon (Phone Number)

Nama Ibu Kandung (Name Of Biologic Mother)*

Nomor Telepon (Phone Number)

Penghasilan Orang tua per bulan (Monthly Salary) *
3 - 5 Million
> 5 - 10 Million
10 Million
> 10 Million

Pekerjaan Orang Tua (parents' job) *
PNS (government employees)
Pegawai Swasta (private employees)
TNI(army)
Polri (Police)
Profesional
Wirausaha (Entrepreneur)
Lain-lain (Etc)

Foto (photo)