Formulir

Pendaftaran
Mahasiswa Baru
Tahun Akademik 2010/2011 PROGRAM S1 STIK - SMART ENGINEER
KERJASAMA INSTIPER JOGJA – PT. SMART Tbk
No. Pendaftaran:

1. Nama Lengkap Calon : .................................................................................................................................................................................................................

2. Tempat Lahir : Kec.: .................................................... Kab. : ........................................................... Prop. : ............................................................
3. Tanggal Lahir : .................................................................................................................................................................................................................
3. Ijasah yang dimiliki

Jenjang Nama Sekolah Tahun Propinsi

SD
SMP
SMA/ MA/ SMK
Jurusan

4. Alamat SMA/ MA/ SMK Asal : .................................................................................................................................................................................................................

: .......................................................................................................................... telp. : .........................................................................
5. Data Prestasi : Nilai STTB: .................... Terbaik di kelas no: .................. Juara: .................. pada kejuaraan: .........................................
6. Alamat Asal (lengkap) : ................................................................................................................................................................................................................
: Kab.: .................................................... Prop. : ...................................................... Telp./ HP : .......................................................
6. Alamat di Jogja : ................................................................................................................................................................................................................
: Kab.: .................................................... Prop. : ...................................................... Telp./ HP : .......................................................
7. Agama : Islam Katolik Kristen Hindu Budha

8. Nama Lengkap Ayah/ Wali : ................................................................................................................................................................................................................

9. Pendidikan Ayah : SD SMP SMA Akademi Sarjana S2/S3
10. Pekerjaan Ayah : PNS BUMN Swasta Swasta Perkebunan Wiraswasta
11. Alamat Kantor Ayah/ Wali* : .................................................................................................................................................................................................................
: .......................................................................................................................... telp. : .........................................................................

12. Nama Lengkap Ibu : ................................................................................................................................................................................................................

13. Pendidikan Ibu : SD SMP SMA Akademi Sarjana S2/S3
14. Pekerjaan Ibu : PNS BUMN Swasta Swasta Perkebunan Wiraswasta
15. Alamat Kantor Ibu : .................................................................................................................................................................................................................
: .......................................................................................................................... telp. : .........................................................................

16. Nilai Selama Sekolah di SLTA

Uraian Kelas I Kelas II Kelas III Nilai Ujian

Semester 1 2 3 4 5 6 Nasional
A. Nilai Mata Pelajaran
1. Bahasa Indonesia
2. Bahasa Inggris
3. Matematika
4. Fisika
5. Kimia
6. Biologi
B. Jumlah Pelajaran di Rapor
C. Jumlah Nilai di Rapor

Demikian data ini dibuat sesuai dengan sebenarnya

......................................, ..................................................... 2010

Calon Mahasiswa

Foto
( ................................................................. )

*) Pilih salah satu dengan memberi tanda ( )

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