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Lampiran
: 2 |
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| Lampiran SK Kepala
Dinas Pendidikan |
| Kabupaten / Kota
.................................... |
| Tentang Penetapan
Siswa Penerima Dana BKM APBN |
| Nomor SK: |
| (Periode
Bulan
......................s.d.................. 2012) |
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Kabupaten/Kota |
: ................... |
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Jumlah Dana |
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: …………………………………… |
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Propinsi |
: Jawa Timur |
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Jumlah Penerima BKM |
: ………………. siswa |
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| |
Nama Siswa Penerima |
Nomor |
Nomor |
Jenis Kelamin |
Kelas |
Nama |
Alamat Rumah Lengkap (mencakup: jalan. Desa/kelurahan,
kecamatan, kode pos) |
Jarak Rmh ke Sek. (Km) |
Penghasilan rata2 Ortu/ Wali per Bulan |
Rata-rata |
Transportasi siswa ke Sklh |
Pekerjaan Orangtua Siswa |
| No. |
Per Sekolah |
Rekening |
Induk |
Orangtua/Wali |
Iuran Siswa |
| |
|
Sekolah |
Siswa |
L |
P |
X |
XI |
XII |
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per Bulan |
A |
B |
C |
D |
A |
B |
C |
D |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
22 |
| A |
SMA .... |
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4 |
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| 1 |
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1 |
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| 2 |
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1 |
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| 3 |
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1 |
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| 4 |
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| 5 |
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1 |
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| B |
SMA .... |
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3 |
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| 1 |
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1 |
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| 2 |
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| 3 |
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1 |
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| 4 |
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1 |
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| 5 |
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TOTAL |
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7 |
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| Keterangan
: |
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| 1) |
Transportasi siswa : |
2) |
Profesi Orangtua : |
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* hasil penjumlahan per sekolah |
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…………………………..………………. ,
2012 |
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A : Berjalan kaki |
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A : Petani/Nelayan/Buruh |
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Kepala Dinas Pendidikan |
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B : Sepeda angin |
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B : Pedagang/UKM/Wiraswasta |
|
* isi dengan angka 1 |
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Kabupaten / Kota
....................... |
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C : Kendaraan Umum |
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C : Guru/PNS/TNI |
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D : Sepeda motor
pribadi |
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D : Karyawan Swasta |
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* hasil penjumlahan per kabupaten/kota |
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| 3) |
Berilah tanda angka satu
( 1 ) yang sesuai |
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pada kolom 5 s.d. 9 dan
15 s.d. 22 |
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( …………………………...…………. ) |
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