BIODATA MAHASISWA

FAKULTAS PERIKANAN DAN ILMU KELAUTAN

UNIVERSITAS BRAWIJAYA
NAMA MAHASISWA
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NIM

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PROGAM STUDI
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TEMPAT, TGL LAHIR
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AGAMA

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NO. TELP/HP
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ASAL SEKOLAH
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ALAMAT DI MALANG
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DATA ORANG TUA / WALI

NAMA AYAH
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NAMA IBU
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NO. TELP/ HP
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ALAMAT LENGKAP:
JL............................................................................................NO..............

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DESA/KELURAHAN......................................................................................

KECAMATAN..............................................................................................

KODYA/KABUPATEN..................................................................................

PROVINSI...................................................................................................
KODE
POS..................................................................................................
CATATAN :
1. FORM DIISI DENGAN HURUF BALOK
2. MELAMPIRKAN PASPHOTO TERBARU BERWARNA UKURAN 3X4 (2
LEMBAR)