<table width="100%" align="center" cellspacing="0" cellpadding="0" style="font-f

amily: Arial; font-size:12pt;">

<tr>
<td align="center">
<font size="5"><b>UNIVERSITAS SRIWIJAYA</b></font><br />
<font size="5"><b>KARTU INDUK DATA MAHASISWA</b></font><br />
<font size="5"><b>TA. 2013/2014</b></font><br />
</td>
</tr>
</table>
<hr>
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<td>Nama</td>
<td>:</td>
<td><strong>ANDREY DWI SAPUTRA</strong></td>
</tr>
<tr>
<td>Nomor Pendaftaran</strong></td>
<td>:</td>
<td><strong>4132301375</strong></td>
</tr>
<tr>
<td>Program Studi </td>
<td>:</td>
<td>
TEKNIK KIMIA
</td>
</tr>
<tr>
<td valign="top">Strata Pendidikan</td>
<td valign="top">:</td>
<td>
S1 (Strata 1)
</td>
</tr>
<tr>
<td valign="top">UKT (Uang Kuliah Tunggal) Yang Harus Dibayar</td>
<td valign="top">:</td>
<td>
<b>Rp. 9.120.000,00</b> </td>
</tr>
<tr>
<td valign="top">Bank Tempat Pembuatan KPM</td>
<td valign="top">:</td>
<td>
<strong>BANK SUMSEL BABEL</strong>
</td>
</tr>
<tr>
<td colspan="3">&nbsp;</td>
</tr>
<tr>
<th colspan="3" align="left">
1. DATA PRIBADI
<hr size="1px">

</th>
</tr>
<tr>
<td valign="top">Tempat Lahir</td>
<td valign="top">:</td>
<td>
PALEMBANG
</td>
</tr>
<tr>
<td valign="top">Tanggal Lahir</td>
<td valign="top">:</td>
<td>
06 Januari 1996 </td>
</tr>
<tr>
<td valign="top">Tinggi Badan (cm)</td>
<td valign="top">:</td>
<td>
178 cm
</td>
</tr>
<tr>
<td valign="top">Jenis Kelamin</td>
<td valign="top">:</td>
<td>
LAKI-LAKI
</td>
</tr>
<tr>
<td valign="top">Golongan Darah</td>
<td valign="top">:</td>
<td>
B
</td>
</tr>
<tr>
<td valign="top">Penyakit penting yang pernah dialami</td>
<td valign="top">:</td>
<td>
</td>
</tr>
<tr>
<td valign="top">Agama</td>
<td valign="top">:</td>
<td>
BUDHA </td>
</tr>
<tr>
<td valign="top">Anak Nomor Ke-</td>
<td valign="top">:</td>
<td>
2
dari
3
orang bersaudara
</td>
</tr>
<tr>
<td valign="top">Kewarganegaraan</td>
<td valign="top">:</td>
<td>
INDONESIA ASLI </td>
</tr>

<tr>
<td valign="top">Alamat Tinggal Selama Mengikuti Pendidikan</td>
<td valign="top">:</td>
<td>
JL. AKBP H.UMAR LRG.OGAN RT.04 NO.411 PALEMBANG, KOTA PALEMBANG, SUMATER
A SELATAN
</td>
</tr>
<tr>
<td valign="top">No. Telepon/HP</td>
<td valign="top">:</td>
<td>
085718554312
</td>
</tr>
<tr>
<td valign="top">Status</td>
<td valign="top">:</td>
<td>
BELUM KAWIN,
memiliki anak:
0
orang
</td>
</tr>
<tr>
<td valign="top">Pekerjaan</td>
<td valign="top">:</td>
<td>
BELUM BEKERJA,
sebagai:
</td>
</tr>
<tr>
<td valign="top">Pendapatan/bulan (Rp)</td>
<td valign="top">:</td>
<td>
Rp. 0,00
</td>
</tr>
</table>
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th align="left">
2. DATA PENDIDIKAN
<hr size="1px">
</th>
</tr>
</table>
<table border="1" width="100%" cellpadding="0" cellspacing="0" style="font-famil
y: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th>Tingkat</th>
<th>Nama Sekolah</th>
<th>Jurusan</th>
<th>Lokasi Kab/Kodya/Prop</th>
<th>Tahun Lulus</th>
</tr>

<tr>
<td>SD</td>
<td align="center">
SD NEGERI 190 </td>
<td align="center">
</td>
<td align="center">
KOTA PALEMBANG, SUMATERA SELATAN
<td align="center">
2007
</td>

</td>

</tr>
<tr>
<td>SLTP</td>
<td align="center">
SMP XAVERIUS 1 </td>
<td align="center">
</td>
<td align="center">
KOTA PALEMBANG, SUMATERA SELATAN
<td align="center">
2010
</td>

</td>

</tr>
<tr>
<td>SLTA</td>
<td align="center">
SMA XAVERIUS 1 </td>
<td align="center">
IPA
</td>
<td align="center">
KOTA PALEMBANG, SUMATERA SELATAN

</td>

<td align="center">
2013
</td>
</tr>
</table>
<br />
<table border="1" width="100%" cellpadding="0" cellspacing="0" style="font-famil
y: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<td rowspan="4">Ijazah & Nilai Akademik Pendidikan Terakhir</td>
<td>a. Tahun Lulus</td>
<td>:</td>
<td>
2013
</td>
</tr>
<tr>
<td>b. Nomor Ijazah</td>
<td>:</td>
<td>
DN-11 Ma 0003813
</td>
</tr>
<tr>
<td>c. Jumlah Mata Pelajaran</td>
<td>:</td>
<td>
6
</td>

</tr>
<tr>
<td>d. Nilai Rata-Rata/IPK</td>
<td>:</td>
<td>
8.1
</td>
</tr>
<tr>
<td rowspan="2">Nilai Ujian Nasional</td>
<td>a. Jumlah Mata Pelajaran</td>
<td>:</td>
<td>
6
</td>
</tr>
<tr>
<td>b. Nilai Rata-Rata</td>
<td>:</td>
<td>
8.1
</td>
</tr>
</table>
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th align="left">3. PENGALAMAN ORGANISASI
<hr size="1px">
</th>
</tr>
</table>
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<td colspan="3"><strong>Organisasi Intra Sekolah</strong></td>
</tr>
<tr>
<td>Nama Organisasi</td>
<td>:</td>
<td>
</td>
</tr>
<tr>
<td>Tahun</td>
<td>:</td>
<td>
</td>
</tr>
<tr>
<td>Jabatan</td>
<td>:</td>
<td>
</td>
</tr>
<tr>
<td colspan="3"><strong>Organisasi Ekstra Sekolah</strong></td>
</tr>
<tr>

<td>Nama Organisasi</td>
<td>:</td>
<td>
</td>
</tr>
<tr>
<td>Tahun</td>
<td>:</td>
<td>
</td>
</tr>
<tr>
<td>Jabatan</td>
<td>:</td>
<td>
</td>
</tr>
</table>
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th align="left">4. PRESTASI/PENGHARGAAN/TANDA JASA
<hr size="1px">
</th>
</tr>
</table>
<table border="1" width="100%" cellpadding="0" cellspacing="0" style="font-famil
y: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th>Tingkat</th>
<th>Bidang</th>
<th>Sebagai</th>
<th>Tahun Lulus</th>
</tr>
<tr>
<td>Sekolah</td>
<td align="center">
</td>
<td align="center">
</td>
<td align="center">
</td>
</tr>
<tr>
<td>Daerah</td>
<td align="center">
</td>
<td align="center">
</td>
<td align="center">
</td>
</tr>
<tr>
<td>Nasional</td>
<td align="center">
</td>
<td align="center">

</td>
<td align="center">
</td>
</tr>
<tr>
<td>Internasional</td>
<td align="center">
</td>
<td align="center">
</td>
<td align="center">
</td>
</tr>
</table>
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th align="left">5. BAKAT/HOBI/KEGEMARAN
<hr size="1px">
</th>
</tr>
</table>
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<td>1.</td>
<td>
MEMBACA BUKU
</td>
</tr>
<tr>
<td>2.</td>
<td>
SEPAK BOLA
</td>
</tr>
</table>
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<th align="left">6. DATA KELUARGA
<hr size="1px">
</th>
</tr>
</table>
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<td colspan="3"><strong>AYAH</strong></td>
</tr>
<tr>
<td>Nama</td>
<td>:</td>
<td>
GUNAWAN </td>
</tr>
<tr>

<td>Pekerjaan</td>
<td>:</td>
<td>
SWASTA </td>
</tr>
<tr>
<td>Tempat Lahir</td>
<td>:</td>
<td>
PALEMBANG
</td>
</tr>
<tr>
<td>Tanggal Lahir</td>
<td>:</td>
<td>
20 April 1954 </td>
</tr>
<tr>
<td>Pendidikan Terakhir</td>
<td>:</td>
<td>
SMA
</td>
</tr>
<tr>
<td>Penghasilan Sebulan (Rp)</td>
<td>:</td>
<td>
Rp. 4.000.000,00
</td>
</tr>
<tr>
<td>Alamat Rumah</td>
<td>:</td>
<td>
JL. AKBP H.UMAR LRG.OGAN RT.04 NO.411 PALEMBANG, KOTA PALEMBANG, SUMATER
A SELATAN
</td>
</tr>
<tr>
<td>No. Telp</td>
<td>:</td>
<td>
0711418041
</td>
</tr>
<tr>
<td>No. HP</td>
<td>:</td>
<td>
08127871649
</td>
</tr>
</table>
<br />
<br />
<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
amily: Arial, Helvetica, sans-serif; font-size:11px">
<tr>
<td colspan="3"><strong>IBU</strong></td>
</tr>
<tr>
<td>Nama</td>
<td>:</td>

<td>
MERY FANI

</td>

</tr>
<tr>
<td>Pekerjaan</td>
<td>:</td>
<td>
</td>
</tr>
<tr>
<td>Tempat Lahir</td>
<td>:</td>
<td>
PALEMBANG
</td>
</tr>
<tr>
<td>Tanggal Lahir</td>
<td>:</td>
<td>
31 Agustus 1960 </td>
</tr>
<tr>
<td>Pendidikan Terakhir</td>
<td>:</td>
<td>
SMA
</td>
</tr>
<tr>
<td>Penghasilan Sebulan (Rp)</td>
<td>:</td>
<td>
Rp. 0,00
</td>
</tr>
<tr>
<td>Alamat Rumah</td>
<td>:</td>
<td>
JL. AKBP H.UMAR LRG.OGAN RT.04 NO.411 PALEMBANG, KOTA PALEMBANG, SUMATER
A SELATAN
</td>
</tr>
<tr>
<td>No. Telp</td>
<td>:</td>
<td>
0711418041
</td>
</tr>
<tr>
<td>No. HP</td>
<td>:</td>
<td>
08127871649
</td>
</tr>
</table>

<!--

<br />
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<br />
<table width="100%" align="center" cellspacing="0" cellpadding="0" style="font-f
amily: Arial; font-size:12pt;">
<tr>
<td align="center">
<font size="3"><b>FORMULIR REGISTRASI</b></font><br />
<font size="3"><b>MAHASISWA BARU UNIVERSITAS SRIWIJAYA</b></fo
nt><br />
<font size="3"><b>TAHUN AKADEMIK 2013/2014</b></font><br />
</td>
</tr>
</table>
<hr>
<p style="font-family: Arial; font-size:10pt;">
Kepada Yth. Rektor <br />
u.p Kepala BAAK <br />
Universitas Sriwijaya
</p>
<p style="font-family: Arial; font-size:10pt;">
Saya yang bertanda tangan di bawah ini:
</p>
<table width="100%" style="font-family: Arial; font-size:10pt;">
<tr>
<td>a.</td>
<td>Nama</td>
<td>:</td>
<td>ANDREY DWI SAPUTRA</td>
</tr>
<tr>
<td>b.</td>
<td>Tempat/Tanggal Lahir</td>
<td>:</td>
<td>PALEMBANG / 06 Januari 1996</td>
</tr>
<tr>
<td>c.</td>
<td>Asal SMU</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td>d.</td>
<td>Alamat SMU</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td>e.</td>

<td>Jalur Seleksi</td>
<td>:</td>
<td>USM 2013</td>
</tr>
<tr>
<td>f.</td>
<td>No. Test</td>
<td>:</td>
<td>4132301375</td>
</tr>
<tr>
<td>g.</td>
<td>Alamat Tinggal</td>
<td>:</td>
<td>JL. AKBP H.UMAR LRG.OGAN RT.04 NO.411 PALEMBANG, KOTA PALEMBANG, SUM
ATERA SELATAN</td>
</tr>
<tr>
<td>h.</td>
<td>No. Telepon/HP</td>
<td>:</td>
<td>085718554312</td>
</tr>
</table>
<p style="font-family: Arial; font-size:10pt;">
Bermaksud melaksanakan registrasi sebagai mahasiswa Universitas Sriwijaya:
</p>
<table width="100%" style="font-family: Arial; font-size:10pt;">
<tr>
<td>Program Studi</td>
<td>:</td>
<td>
TEKNIK KIMIA
</td>
</tr>
<tr>
<td>Strata Pendidikan</td>
<td>:</td>
<td>S1 (Strata 1)</td>
</tr>
</table>
<p style="font-family: Arial; font-size:10pt;">
Terlampir kami sampaikan berkas persyaratan sebagai berikut:
</p>
<table width="100%" style="font-family: Arial; font-size:10pt;">
<tr>
<td>a.</td>
<td>Foto copy ijazah terakhir yang telah dilegalisir.</td>
</tr>
<tr>
<td>b.</td>
<td>Bukti pemeriksaan kesehatan dan bebas narkoba dari UPT Klinik Unsri.
</td>
</tr>
<tr>
<td valign="top">c.</td>
<td>

Formulir berkas registrasi (Surat Pernyataan Mahasiswa, Kartu Data Induk

Mahasiswa,
Blanko Pembuatan Kartu Pengenal Mahasiswa/KPM).
</td>
</tr>
<tr>
<td valign="top">d.</td>
<td>
Lain-lain, sebutkan ....................................................
................................................................................
.....
<br />
<br />
<br />
<br />
<br />
</td>
</tr>
</table>
<table width="100%" style="font-family: Arial; font-size:10pt;">
<tr>
<td align="right">Indralaya,..........................</td>
</tr>
<tr>
<td align="right">Calon mahasiswa, ybs.</td>
</tr>
<tr>
<td align="right">&nbsp;</td>
</tr>
<tr>
<td align="right">ANDREY DWI SAPUTRA</td>
</tr>
<tr>
<td align="right"></td>
</tr>
</table>
-->