Form – 1

IDENTITAS LEMBAGA/INSTANSI/DUNIA USAHA/DUNIA INDUSTRI

DAN IDENTITAS SISWA PESERTA PRAKTIK KERJA LAPANGAN (PKL)

1. IDENTITAS LEMBAGA/INSTANSI/DUNIA USAHA/ DUNIA INDUSTRI

a. Nama Lembaga/Instansi/Du/Di
b. Bidang Usaha/Jenis Kegiatan
c. A l a m a t
d. Nomor Telepon / Faximile
e. Nama Kepala/Pimpinan/Direktur
f. Nama Pembimbing/Instruktur
: __________________________________________________
: ________________________________________________
: _________________________________________________
_______________________________________________
: _________________________________________________
: ______________________________________________
: _________________________________________________

2. IDENTITAS SISWA/PESERTA
a. Nama Lengkap
b. Nomor Induk Siswa ( NIS )
c. Tempat / Tanggal Lahir
d. Golongan Darah
e. Sekolah
f. Alamat Sekolah
g. Nomor Telepon / Faximile
h. Nama Orang Tua / Wali
i. Alamat Orang Tua / Wali
j. No. Telepon Orang Tua / Wali
: ____________________________________________ L / P*)
: ________________ Kelas: ___________________________
:_________________________, ______ / ______ /_________
: O / A / B / AB *)
: MAN 2 Banjarnegara
: Jl. Letjend Suprapto 95A Banjarnegara
:Telp.(0286) 591130 / Faks. (0286) 593271
: __________________________________________________
: __________________________________________________
__________________________________________________
:_________________________________________________

____________________, __________________________

Pembimbing Tempat PKL,

Pas Foto
3 X 4 cm

tanda tangan, nama jelas dan stempel

Keterangan :
 Diisi dengan huruf Balok/Kapital
*)
 Coret yang tidak perlu
 Stempel agar dikenakan pada sebagian foto siswa
 Foto berwarna terbaru 3x4 cm
 JADWAL PELAKSANAAN PKL
JAM MASUK, ISTIRAHAT DAN PULANG

HARI JAM MASUK JAM ISTIRAHAT JAM PULANG

SENIN

SELASA

RABU

KAMIS

JUM’AT

SABTU

MINGGU

Catatan : ……………………………............................................................................................
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Pembimbing Tempat PKL,

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 Form – 2

JURNAL KEGIATAN SISWA SECARA BERKALA

Mulai Selesai Paraf

No Tanggal Kegiatan
Pukul Pukul Pembimbing

..........................................., ……………....……

Pembimbing Tempat PKL,

............................................................................
 Form – 3

DAFTAR KEHADIRAN PESERTA PKL

Bulan / Tanggal / Paraf Ket.

Juni Juli
No. Nama Kelas
25 26 2 2 29 30 2 3 4 5 6 7 9 10 11 12 13 14
7 8

..........................................., ……………....……

Pembimbing Tempat PKL,

............................................................................
 Form – 4

LEMBAR BIMBINGAN
DENGAN PEMBIMBING PKL DI MADRASAH

No Tanggal Uraian Kegiatan Paraf

Pembimbing

Banjarnegara, .....…………..………................
Pembimbing PKL,

____________________________________
NIP.