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Tanggal Revisi: 17 Mei 2013

Tanggal Mulai Berlaku: 11 Sept. 2008

F50-04.01.00.002

KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

UNIVERSITAS JEMBER- PASCASARJANA

JL. KALIMANTAN 37 KAMPUS TEGALBOTO JEMBER 68121


TLP. (0331) 323567 (HUNTING), 339322, 330224, EXT. 326 FAX : (0331) 339322, 321818

FORMULIR PENDAFTARAN CALON MAHASISWA


TAHUN AKADEMIK ../..
1. Nomor urut:
(diisi oleh panitia)

Diisi dengan huruf balok warna hitam

2. Program Studi
Tempelkan pasfoto
Ukuran 4 cm x 6 cm
(difoto dalam waktu 6 bulan
terakhir)

3. Sumber Biaya:

BPPS
Instansi

Isikan tanda X dalam


kotak yang sesuai

Mandiri
Lainnya:
4. Nama lengkap:
5. NIP/Yayasan:

6. Ijasah Perguruan tinggi yang sudah diperoleh


6.1 Program Sarjana/Program Doktor*)
Nama PT (jangan disingkat): ...............................................................................................................
6.2 Fakultas: .....................................................................................................................................
..........................................................................................................................................................
6.3 Jurusan:.......................................................................................................................................
..........................................................................................................................................................
6.4 Program Studi: ............................................................................................................................
.........................................................................................................................................................

7. Lamaran kepada Program Pascasarjana PT Lain untuk Tahun Akademik ........../.......


7.1 Program Magister/Program Doktor*) Program Studi : .....................................................................

7.2 Perguruan Tinggi: .......................................................................................................................


8. Perguruan Tinggi/ Instansi Asal Pelamar
8.1 PTN (Nama PT/Fakultas/Jurusan):

...............................................................................................

.........................................................................................................................................................
8.2 PTS (Kopertis I-XII/Nama PT/Fakultas/Jurusan): ............................................................................
.........................................................................................................................................................
8.3 Instansi lain (Dep/Ditjen Badan/Satuan Induk/Satuan Kerja): ..........................................................
........................................................................................................................................................
8.4 Belum/Tidak Bekerja: ...................................................................................................................
..........................................................................................................................................................
9. Program Pascasarjana yang pernah diikuti tetapi tidak selesai
9.1

Nama PT Penyelenggara: ............................................................................................................

.........................................................................................................................................................
9.2 Program/Bidang Studi:
.........................................................................................................................................................
9.3 Lama (bulan): ............................................................................................................................
9.4 Tahun : .....................................................................................................................................

*) Coret yang tidak perlu