DATA PRIBADI MAHASISWA

TAHUN AKADEMIK __________ / __________

1. Nama

: ______________________________________

2. Jenis Kelamin

: ______________________________________

3. NIM

: ______________________________________

4. Tempat Lahir

: ______________________________________

5. Tanggal Lahir

: ______________________________________

6. Alamat

: ______________________________________
______________________________________
No. Telp. / HP __________________________

7. Kabupaten / Kota

: ______________________________________

8. Propinsi

: ______________________________________

9. Kode Pos

: ______________________________________

10. Fakultas

: ______________________________________

11. Jurusan

: ______________________________________

12. Program Studi

: ______________________________________

13. Semester

: ______________________________________

14. Nama Ayah

: ______________________________________

15. Status Ayah

: ______________________________________

16. Nama Ibu

: ______________________________________

17. Status Ibu

: ______________________________________

18. Pekerjaan Ayah

: ______________________________________

19. Penghasilan Ayah per Bulan

: ______________________________________

20. Pekerjaan Ibu

: ______________________________________

21. Penghasilan Ayah per Bulan

: ______________________________________

22. Anak ke __________________________ dari ______________________bersaudara

23. Alamat Orang Tua

: ______________________________________

______________________________________
No. Telp / HP __________________________
24. Kabupaten / Kota

: ______________________________________

25. Propinsi

: ______________________________________

26. Kode Pos

: ______________________________________

27. Status Beasiswa

: ______________________________________

28. Periode

: ______________________________________

29. Tanggal Permohonan

: ______________________________________

Surakarta, ____________________________
(ttd)