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

____________________, __________________________

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,

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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

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Pembimbing Tempat PKL,

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Form – 4

LEMBAR BIMBINGAN
DENGAN PEMBIMBING PKL DI MADRASAH

No Tanggal Uraian Kegiatan Paraf


Pembimbing

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

____________________________________
NIP.