TAHUN
PELAJARAN: ………………/ ……………….
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Nomor
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Nama
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L/P
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Lulus/
Tidak Lulus
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Nomor
Tanggal Ijazah
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Melanjutkan
Ke
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Urut
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Induk
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Induk Siswa
Nasional
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CATATAN: ......................,
....................................
GURU KELAS KEPALA
SEKOLAH
NAMA :
NIP :
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