BIODATA CALON PESERTA BEASTUDI ETOS 2014

No, Registrasi Peserta

Tahun Masuk Etos

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

DATA DIRI PENDAFTAR

Nama Peserta
: ...............................................................................................................
Jenis Kelamin
: ...............................................................................................................
Tinggi / berat badan
: ...............................................................................................................
Hobi / kegemaran
: ...............................................................................................................
Penyakit yang pernah diderita : ...................................................................................................
Golongan darah
: ...............................................................................................................
Asal suku
: ...............................................................................................................
Nomor Hp
: ...............................................................................................................
Asal SMA
: ...............................................................................................................
Alamat email
: ...............................................................................................................
Alamat asal
Nama jalan

: ...............................................................................................................
...............................................................................................................
Kelurahan
: ...............................................................................................................
Kecamatan
: ...............................................................................................................
Kebupaten
: ...............................................................................................................
Propinsi
: ...............................................................................................................
No. Telepon
: ...............................................................................................................
Keterangan Telepon : milik pribadi / milik saudara / milik tetangga * (wajib diisi)
atas nama ...................................................................................................................................
Jarak antara alamat saat ini dan tempat daftar : ..................KM
Alamat sekarang ( diisi jika tidak sama dengan alamat asal )
Nama jalan
: ...............................................................................................................
...............................................................................................................
Kelurahan
: ...............................................................................................................
Kecamatan
: ...............................................................................................................
Kebupaten
: ...............................................................................................................
Propinsi
: ...............................................................................................................
No. Telepon
: ...............................................................................................................
Keterangan Telepon : milik pribadi / milik saudara / milik tetangga * (wajib diisi)
atas nama ...................................................................................................................................

DATA KELUARGA ( Wajib diisi )

No.

Nama

Status Dalam
Keluarga

Umur

Pekerjaan

Jumlah Penghasilan *
(wajib diisi)

1
2
3
4
5
6
7
Anak ke dari . bersaudara ( Wajib diisi )
Apakah ada anggota keluarga yang pernah menerima Beasiswa SMART/ Beastudi Etos ?

Penyokong pendapatan lainnya (selain saudara kandung)

Nama
: ...............................................................................................................
Pekerjaan
: ................................. (sebutkan jenis pekerjaan dengan lebih spesifik)
Umur
: ...............................................................................................................
Hubungan dengan anda
: ...............................................................................................
Jumlah penghasilan / bulan (sebutkan nominalnya) : ................................................................
Jumlah pendapatan yang diberikan : ...................................................................................
Jumlah tanggunganya
: ...................................................................................
No. Telp / Hp yang dapat dihubungi : ...................................................................................
Kecerdasan Sosial Pendaftar

a) Jelaskan pendapat anda tentang keluarga anda

.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
b) Tuliskan & deskripsikan tentang sahabat akrab anda
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
c) Jelaskan kondisi ekonomi keluarga
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
DATA PRESTASI
Akademik / Sekolah
No.
Bidang Perlombaan
1
2
3
4
5
6

Peringkat / Rangking

Prestasi Luar Sekolah

No.

Nama Lomba

Ruang Lingkup (Kec / Kab /

Prop / Nas / Inter)

Peringkat

Jabatan

Tahun
Kepengurusan

1
2
3
4
5
6
7
PENGALAMAN ORGANISASI
No.

Nama Organisasi

1
2
3
4
5
6
7
HAL KHUSUS
Kegiatan pasca lulus SMA : ...................................................................................................
Tahun masuk kuliah
: ...................................................................................................
Tujuan dan harapan mengikuti program
: .......................................................................
Universitas / Fakultas / Jurusan yang dituju
Pilihan 1 (Wajib diisi )
Universitas
: ...................................................................................................
Fakultas
: ...................................................................................................
Jurusan
: ...................................................................................................
Pilihan 2 (Wajib diisi )
Universitas
Fakultas
Jurusan

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

Pilihan 3 (jika memilih IPC)

Universitas
: ...................................................................................................
Fakultas
: ...................................................................................................
Jurusan
: ...................................................................................................

Kelebihan diri
: ...................................................................................................
Kelemahan diri
: ...................................................................................................
Cita-cita
- 1 Tahun mendatang
: ...........................................................................
- 5 Tahun mendatang (setelah lulus kuliah) : ...........................................................................
- 10 Tahun mendatang
: ...........................................................................
Motto hidup
: ...........................................................................
............................................................................
Buku bacaan favorit
: ...........................................................................
Tokoh pemimpin idola
: ...........................................................................
Kesuksesan yang pernah diraih / dirasakan : ...........................................................................
Tuliskan karangan singkat tentang kisah hidup anda dari kecil sampai sekarang (Sekurangkurangnya 1 Halaman Folio )
,

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ket* : coret yang tidak perlu