KEMENTRIAN PENDIDIKAN DAN KEBUDAYAAN

ORGANISASI KEMAHASISWAAN INTRA

POLITEKNIK NEGERI MALANG
Jalan Soekarno Hatta 9 PO. BOX 04 Malang 65141
Telp (0341)404424-404425 (pswt. 2422)Fax. (0341) 404420
FORMULIR PENDAFTARAN
DATA PRIBADI
NAMA LENGKAP
NIM

4x6
Cantumkan
Foto Diri
Terbaru

: ......

: ..........

JURUSAN / PROGRAM STUDY

: ............/..............

TEMPAT / TANGGAL LAHIR

: ..........

JENIS KELAMIN

: PRIA / WANITA

AGAMA

: ...........

HOBI

: .......

ALAMAT RUMAH

: ...................................................

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ALAMAT KOST (JIKA KOST)

: .......................................................

NO.TELP / HP

: ........../.......................................................................................

E-MAIL / FACEBOOK

: ./.........................

*ORGANISASI YANG DIPILIH

: ..................................................................................................................................

*ORGANISASI LAIN YANG DIIKUTI : ..........................................................................................................................

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MOTIVASI MENGIKUTI ORGANISASI

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Sekretariat : Gedung AS Kampus 2 POLITEKNIK NEGERI MALANG
Jalan Soekarno Hatta 9 PO. BOX 04 Malang 65141
Telp (0341)404424-404425 (pswt. 2422)Fax. (0341) 404420

website : poltek-malang.ac.id

KEMENTRIAN PENDIDIKAN DAN KEBUDAYAAN

ORGANISASI KEMAHASISWAAN INTRA

POLITEKNIK NEGERI MALANG
Jalan Soekarno Hatta 9 PO. BOX 04 Malang 65141
Telp (0341)404424-404425 (pswt. 2422)Fax. (0341) 404420
Pengalaman Organisasi
Lingkup

Organisasi

(sekolah, daerah, nasioal)

Jabatan

Periode / Tahun
(urutkan dari yang terbaru)

**Prestasi
(akademik, olahraga, seni budaya)
Nama Kegiatan

Prestasi

Lingkup

Tahun

(sekolah, daerah, nasional,

internasional)

(urutkan dari yang

terbaru)

Semua data/keterangan tersebut saya buat dengan jujur dan benar, dan apabila dikemudian hari diketahui
data/keterangan tersebut tidak benar, maka saya bersedia menerima sanksi .

Malang,

2013

(.)
Nb : **( Harap melampirkan foto copy sertifikat )
*(BEM, HMM, HME, HMS, HMA, HIMANIA, HMTK, PLFM, KOMPEN, RISPOL, KMK, MENWA,
PASTI, GG, USMA, TALITAKUM, BKM, PP, OR, SENI THEATRISIC)
Sekretariat : Gedung AS Kampus 2 POLITEKNIK NEGERI MALANG
Jalan Soekarno Hatta 9 PO. BOX 04 Malang 65141
Telp (0341)404424-404425 (pswt. 2422)Fax. (0341) 404420

website : poltek-malang.ac.id