PROGRAM MAGISTER (S2)ADMINISTRASI NEGARA

FAKULTAS ILMU SOSIAL DAN ILMU POLITIK

UNIVERSITAS MALIKUSSALEH
FORMULIR PENDAFTARAN MAHASISWA
(APPLICATION FOR GRADUATE ADMISSION)
1

BIODATA MAHASISWA (Personal Details)

Nama Lengkap
(Full Name)

Tempat/TglLahir
(Place/Date of Birth)

Jenis Kelamin
(Gender)

: [

Agama
(Religion)

Suku Bangsa
(Race)

Warga negara
(Nationality)

Status Perkawinan
(Marital Status)

No. Kartu (KTP)

(Identity Card No.)

No. Pasport
(Pasport No.)

Alamat
(Address)

No. Tel
(Tel. No.)

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

No. Fak
(Fax. No.)

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

HP
(Mobile)

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

E-mail
(E-mail)

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

]Laki-laki[ ]Perempuan
(Male)
(Female)

ORANG YANG DAPAT DIHUBUNGI SAAT DARURAT / Person to be notified in case of emergency
Nama
(Name)

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

Hubungan
(Relationship)

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

Alamat
(Address)

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

HP
(Mobile)

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

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

LATAR BELAKANG AKADEMIK (Academic Background)

Nama Sekolah dan Alamat
Jurusan
(Name and Address of College) (Departement)

Ijazah yang diperoleh

(Degree Obtained)

Tempat
(Place)

Lamanya
(Time)

Tahun
(Year)

RIWAYAT PEKERJAAN/PENGALAMAN (Employment Details/Experience)

Nama Jabatan
(Name of Positions)

Tanggal Ijazah
(Date of Graduation)

PENDIDIKAN TAMBAHAN (Academic Additional)

Kursus/Pelatihan
(Course/Trainning)

Tahun Masuk
(Year of Entry)

Nama dan Alamat

(Employers name and address)

Rentang Waktu
(From - To)

Keterangan
(Description)

Nilai/Skor
(Grade)

Tahun Lulus
(Year Passed)

KEMAMPUAN BAHASA dan TPA (Language and GMAT Proficiency)

Kemampuan
(Proficiency)

TOEFL
IELTS
TPA

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

Nama Lembaga/Ujian
(Name of Examination/Test)

PUBLIKASI ILMIAH (Professional Publications)

Buku/Jurnal
(Title of Book/Journal)

Tahun Diterbitkan
(Year of Publication)

Nama dan Tempat Penerbitan

(Name and Location of Publication)

BANTUAN KEUANGAN (Financial Support)

Sebutkan sumber bantuan keuangan anda
(Please indicate your source of financial support)
Dibiayai penuh oleh Negara / Beasiswa
(Fully sponsored by government)
Dibiayai penuh oleh Perusahaan / Yayasan
(Fully sponsored by employer)
Biaya sendiri/keluarga
(Supported by myself / my family)
Nama dan alamat penanggung jawab atau organisasi yang akan membayar biaya Anda
(Name and address of person and organization paying your fees)
__________________________________________________________________________________
__________________________________________________________________________________

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

REKOMENDASI AKADEMIK [dua (2) orang]

(Academic Referees) [two (2) people]
Pemberi rekomendasi akademik adalah mereka yang mengenali calon dari bidang akademik (contoh :
Dekan, Dosen, Pimpinan) dan sebaiknya bukan kawan atau saudara sendiri.
(The academic referees must comprise of those who know the applicant in terms of his/her academic
performance [e.g. : Dean, Lecturer, Employer] and should not have any personal acquaintances or relatives)
1) Nama
(Name)

10

: _____________________________

2) Nama
(Name)

: ______________________________

Alamat : _____________________________
(Address)
_____________________________

Alamat : ______________________________
(Address)
______________________________

_____________________________

______________________________

No. HP. : _____________________________

(Mobile)

No. HP. : ______________________________

(Mobile)

Jabatansaatini : _________________________
(Official Postion)

Jabatansaatini : __________________________
(Official Postion)

PERNYATAAN (Declaration)
Dengan ini saya nyatakan bahwa semua keterangan di atas dan dokumen yang saya berikan adalah benar
dan lengkap. Universitas Malikussaleh Lhokseumawe berhak menolak permohonan ini sekiranya
keterangan tersebut didapati palsu dan/atau tidak lengkap.
(I hereby certify that the above information and documents enclosed are true and complete. University of
Malikussaleh Lhokseumawe reserves the right to reject this application if the information given is false and/or
incomplete).

_________________________

__________________________

TandatanganPemohon
(Applicants Signature)

Tanggal
(Date)

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

SURAT REKOMENDASI
(Referees Report)
Surat rekomendasi ini hendaklah diisi oleh pemberi rekomendasi sendiri dan diberikan kepada pemohon untuk
dihantar bersama dengan formulir permohonan.
(This report must be sealed by the referees and forward the envelope to the applicant to be submitted together with
the application form)
BAHAGIAN A : TENTANG CALON
(Part A : The applicant)
Nama Calon
(Name)

: _____________________________________________________________

Program Magister
(Programme of Studies)

: _____________________________________________________________

Alamat
(Address)

: _____________________________________________________________

BAHAGIAN B : PEMBERI REKOMENDASI

(Part B : To be Completed by the referee)
Nama
(Name)

: _____________________________________________________________

Jabatan Saat ini

(Official Position)

: _____________________________________________________________

Alamat
(Address)

: _____________________________________________________________

No. Tel
(Tel. No.)

: _____________________________________________________________

No. Fak
(Fax. No.)

: _____________________________________________________________

HP
(Mobile)

: _____________________________________________________________

E-mail
(E-mail)

: _____________________________________________________________

BAHAGIAN C : LAPORAN PEMBERI REKOMENDASI

(Part C : Referees Report)
a) Berapa lamakah Anda mengenali Calon? ..Tahun
(How long have you known the applicant? No. of years)
b) Bagaimana Anda mengenali Pemohon?
(How do you know the applicant?)
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
c) Dalam kapasitas hubungan apa Anda mengenal Calon?
(What is your relationship to the applicant?)
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
d) Adakah Anda percaya Calon akan mampu untuk menyelesaikan pendidikannya?
(Do you believe that the applicant is prepared for graduate?)
[
] Ya(Yes)
[
] Tidak(No)
* Catatan :Beri tandakan ( X )
Note : Please tick ( X ) whichever applicable

e) Bagaimanakah Anda menilai Calon terhadap hal-hal sebagai berikut? (Tandakan)

(How do you rate the applicant on each of the following?) (Please tick
Cemerlang
(Excellent)

AmatBaik
(Very Good)

Baik
(Good)

Sederhana
(Average)

1) Kecakapan intelek
(Intellectual ability)
2) Kematangan dan kestabilan emosi
(Maturity and emotional )
3) Motivasi
(Motivation)
4) Pengetahuan Umum
(General Knowledge)
5) Inisiatif
(Initiative)
6) Kerjasama
(Ability to cooperate)
7) Tanggung jawab
(Responsibility)

PEMBERI REKOMENDASI (Recommendation)

__________________________
Tandatangan/Nama Jelas
(Referees Signature)

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

___________________________
Tanggal
(Date)

Lemah
(Poor)

SURAT REKOMENDASI
(Referees Report)
Surat remendasi ini hendaklah diisi oleh pemberi rekomendasi sendiri dan diberikan kepada pemohon untuk dihantar
bersama dengan formulir permohonan.
(This report must be sealed by the referees and forward the envelope to the applicant to be submitted together with
the application form)
BAHAGIAN A : TENTANG CALON
(Part A : The applicant)
Nama Calon
(Name)

: _____________________________________________________________

Program Magister
(Programme of Studies)

: _____________________________________________________________

Alamat
(Address)

: _____________________________________________________________

BAHAGIAN B : PEMBERI REKOMENSASI

(Part B : To be Completed by the referee)
Nama
(Name)

: _____________________________________________________________

JabatanSaat ini
(Official Position)

: _____________________________________________________________

Alamat
(Address)

: _____________________________________________________________

No. Tel
(Tel. No.)

: _____________________________________________________________

No. Fak
(Fax. No.)

: _____________________________________________________________

HP
(Mobile)

: _____________________________________________________________

E-mail
(E-mail)

: _____________________________________________________________

BAHAGIAN C : LAPORAN PEMBERI REKOMENDASI

(Part C : Referees Report)
a) Berapa lamakah Anda mengenali Calon? ..Tahun
(How long have you known the applicant? No. of years)
b) Bagaimana Anda mengenali Pemohon?
(How do you know the applicant?)
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
c) Dalam kapasitas hubungan apa Anda mengenal Calon?
(What is your relationship to the applicant?)
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
d) Adakah Anda percaya Calon akan mampu untuk menyelesaikan pendidikannya?
(Do you believe that the applicant is prepared for graduate?)
[
] Ya(Yes)
[
] Tidak(No)

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

e) Bagaimanakah Anda menilai Calon terhadap hal-hal sebagai berikut? (Tandakan)

(How do you rate the applicant on each of the following?) (Please tick
Cemerlang
(Excellent)

Amat Baik
(Very Good)

Baik
(Good)

Sederhana
(Average)

8) Kecakapan intelek
(Intellectual ability)
9) Kematangan dan kestabilanemosi
(Maturity and emotional )
10) Motivasi
(Motivation)
11) Pengetahuan Umum
(General Knowledge)
12) Inisiatif
(Initiative)
13) Kerjasama
(Ability to cooperate)
14) Tanggung jawab
(Responsibility)

PEMBERI REKOMENDASI (Recommendation)

__________________________
Tanda tangan/Nama Jelas
(Referees Signature)

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable

___________________________
Tanggal
(Date)

Lemah
(Poor)

PERSYARATAN PESERTA
Nama Calon
(Name)

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

No. Test
(Test No.)

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

Angkatan

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

Kelas
(Class)

: Khusus / A / B

No

PERSYARATAN

Foto Copy Ijazah (legalisir)

PTN (S-1)
PTS (S-1)

Luar Negeri (S-1)

Foto Copy Transkrip Nilai (legalisir)
PTN (S-1)

PTS (S-1)

3
4

Luar Negeri (S-1)

SK Rektor/Ketua Yayasan
Pas Photo Warna Ukuran
4 x 6 cm = 2 lembar

3 x 4 cm = 6 lembar

5
6
7

2 x 2,5 cm = 4 lembar
FORMULIR PENDAFTARAN
2 BUAH SURAT REKOMENDASI
NILAI
TPA

TOEFL
SURAT KESEHATAN

LENGKAP

BELUM LENGKAP

KETERANGAN

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Lhokseumawe, 2015
Panitia Penerimaan Mahasiswa Baru,

..

NIP.

* Catatan :Beri tandakan ( X )

Note : Please tick ( X ) whichever applicable