Biodata mahasiswa baru fakultas teknik 2013

DATA MAHASISWA
NAMA :.............................................................................................................................................
TEMPAT/TGL LAHIR : .....................................................................................................................
AGAMA : ...........................................................................................................................................
JENIS KELAMIN : LAKI-LAKI / PEREMPUAN.(*)
NIM

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

JURUSAN/ PROG. STUDI : ..............................................................................................................

ALAMAT ASAL : ..............................................................................................................................
ALAMAT DI JEMBER : ....................................................................................................................
NO. TELP / HP : .................................................................................................................................
GOL. DARAH : .................................................................................................................................
RIWAYAT PENYAKIT : ....................................................................................................................
DITERIMA DENGAN JALUR : SNMPTN / SBMPTN / UM UNEJ.(*)
STATUS PERKULIAHAN : BIDIKMISI / REGULER.(*)
DATA ORANG TUA ATAU WALI
NAMA AYAH: ..................................................................................................................................
PEKERJAAN : ................................................................................................................................
ALAMAT : .......................................................................................................................................
NO. TELP/ HP : ...............................................................................................................................
NAMA IBU : ......................................................................................................................................
PEKERJAAN : ................................................................................................................................
ALAMAT : .......................................................................................................................................
NO TELP/ HP : ................................................................................................................................
keterangan : - (*) = coret yang tidak perlu
-

Foto Berwarna 3x4 = 2 Lembar

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