FORMULIR PENDAFTARAN

OSPEK UNY 2014

Nama Lengkap

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

Nama Panggilan

: ...............................................................................................................
FOTO
Tempat, tanggal lahir : ...............................................................................................................
3X4
Jenis Kelamin

: L / P *) (coret yang tidak perlu)

Alamat Rumah Asal

: ...............................................................................................................
: RT / RW : / Kode Pos : .......................................................

Alamat di Yogyakarta : ...............................................................................................................

No Telp / HP

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

Golongan Darah

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

Agama

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

Anak ke

: dari . Bersaudara

Alamat Email

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

Facebook / Twitter

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

Hobi

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

Motto Hidup

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

Cita-cita

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

Tokoh Idola

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

Jalur Masuk

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

Program

: Bidikmisi / non Bidikmisi *) (coret yang tidak perlu)

Jenjang

: D3 / S1 *) (coret yang tidak perlu)

Fakultas / NIM

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

Jurusan / Prodi

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

Jumlah UKT

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

Riwayat Penyakit

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

Makanan Pantangan

: ...............................................................................................................
Vegetarian/Non *) (coret yang tidak perlu)

Alergi

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

Ukuran Baju

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

Pengalaman Mistis

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

Riwayat Pendidikan :
No
Jenjang
1
SD
2 SMP/MTs
SMA/MA/
3
SMK

Nama Institusi

Pengalaman Organisasi :
No
Nama Organisasi
1
2
3
Prestasi yang pernah dicapai :
No
Nama Kejuaraan
1
2
3

Tempat

Tahun Lulus

Jabatan

Periode

Tingkat

Periode

Data Orang tua/ Wali

1. Nama Ayah

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

Pekerjaan

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

No HP

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

Alamat

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

2. Nama Ibu

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

Pekerjaan

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

No HP

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

Alamat

: ...............................................................................................................
Yogyakarta,...2014
Hormat saya,

NIM.