FORMULIR PENDAFTARAN

PEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015
NO PENDAFTARAN

: 2015

001

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................

3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

PETUNJUK TEKNIS
PEMILIHAN PUTRA PUTRI GIZI KOTA MALANG 2015
TAHAP TAHAP PELAKSANAAN
1. Pendaftaran
a. Pendaftaran dibuka sejak tanggal 12 Oktober 2015 11 November
2015
b. Tempat pengumpulan formulir dan pembayaran biaya pendaftaran :
HMP DIII JURUSAN GIZI POLTEKKES KEMENKES MALANG
Senin Jumat : 15.00 18.00 WIB
CP
: Izza 0857 777 37311
Robby
081 555 865 482
biaya pendaftaran bisa di TRANSFER MELALUI REKENING
BANK MANDIRI A/N. NISHAR ZULMI 90000 1986 4967
2. Seleksi tulis, wawancara dan minat bakat dilaksanakan pada :
Hari / Tanggal
: Sabtu, 21 November 2015
Waktu
: 07.30 - selesai
Tempat
: Jurusan Gizi Poltekkes Kemenkes Malang
3. Grand Final dilaksanakan pada :
Hari / Tanggal
: Jumat, 27 November 2015
Waktu
: 18.30 selesai

KRITERIA PESERTA
1. Laki laki / perempuan sehat jasmani dan rohani dan bebas dari penyalah
gunaan NARKOBA
2. Merupakan Warga Negara Indonesia
3. Usia 16-22 tahun dan belum menikah

4.
5.
6.
7.

Tercatat sebagai mahasiswa aktif semester 1-4 Jurusan Gizi di Universitas

se-Malang Raya
IMT normal
Berkepribadian dan berpenampilan menarik, berbakat dan kreatif
Berwawasan luas dan komunikatif
Diutamakan mampu berkomunikasi bahasa inggris dengan baik
PERSYARATAN PENDAFTARAN

1. Fotocopy KTP dan KTM masing masing 2 lembar

2. Pas Foto 4x6 (2 lembar)
3. Foto berwarna terbaru (*)
a. Close Up ukuran 4R (1 lembar)
b. Seluruh badan 4R (1 lembar)
4. Surat izin / rekomendasi dari Jurusan / Prodi
5. Mengisi formulir pendaftaran
6. Seluruh berkas dimasukkan dalam map kertas warna biru (putra)
dan warna merah muda (putri)

*dengan background foto bebas, memakai pakaian bebas, sopan dan rapi.

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

002

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................

3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

003

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................

NO HP
:.................................................................................
......................
TB/BB
ASAL PERGURUAN TINGGI

: ................... cm., .................. kg

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

.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015

NO PENDAFTARAN

: 2015

004

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................

(*) pilih salah satu

(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

005

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg

ASAL PERGURUAN TINGGI

:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

006

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

007

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)

JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

008

NAMA LENGKAP
:
......................................................................................................

NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

009

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................

SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

010

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)

TEMPAT TANGGAL LAHIR

:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

011

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................

TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

012

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................

NAMA ORANG TUA

: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

013

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................

Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

014

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................

ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

015

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................

2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

016

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)

ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
ASAL PERGURUAN TINGGI

: ................... cm., .................. kg

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

.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

017

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...

Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

018

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................

..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
ASAL PERGURUAN TINGGI

: ................... cm., .................. kg

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

.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN

PEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015
NO PENDAFTARAN

: 2015

019

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................
TB/BB
: ................... cm., .................. kg
ASAL PERGURUAN TINGGI
:.................................................................................
.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................

Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARAN
PEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN

: 2015

020

NAMA LENGKAP
:
......................................................................................................
NAMA PANGGILAN
:
......................................................................................................
JENIS KELAMIN
: LAKI LAKI / PEREMPUAN (*)
TEMPAT TANGGAL LAHIR
:
......................................................................................................
USIA
: ............th, agama :
...............................................................
NAMA ORANG TUA
: ................................................................................
......................
ALAMAT ASAL
:
...................................................................................................... ..........................
.........................................................................(**)
ALAMAT MALANG
: ................................................................................
......................
..................................................................................
......................
NO HP
:.................................................................................
......................

TB/BB
ASAL PERGURUAN TINGGI

: ................... cm., .................. kg

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

.................(**)
JURUSAN / FAKULTAS
: ................................................................................
......................
SEMESTER
: ................................................................................
......................
HOBBY
: ................................................................................
......................
TALENTA
: ................................................................................
......................
PRESTASI
:
1. .................................................................................................
Tingkat ..................................................................................
2. ..............................................................................................
...
Tingkat ..................................................................................
3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu
(**) disertai fotocopy KTP dan KTM

Malang, .....................................................
Foto 4x6

(.....................................................................)