No Pendaftaran

(Diisi oleh Petugas)

Prodi Pilihan :

FORMULIR PENDAFTARAN
PROGRAM STRATA 1 (S1)
UNIVERSITAS NAHDLATUL ULAMA
(UNU)

INDONESIA

FORMULIR PENDAFTARAN
PROGRAM STRATA 1 (S1)
UNU INDONESIA
A. DATA PRIBADI
1.

Nama Lengkap*)

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

2.

Tempat Lahir

: ............................................................................. Tgl. Lahir ././......................................

3.

Alamat Rumah

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

4.

No. Tlp / HP

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

5.

E-mail

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

6.

No. KTP / Paspor

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

7.

Jenis Kelamin

: Laki-laki

/ Perempuan**)

B. LATAR BELAKANG PENDIDIKAN

B.1. Pendidikan Dari SD Sampai SLTA
1.

SD/MI

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

Thn. Tamat.........................

2.

SMP/MTs

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

Thn. Tamat.........................

3.

SLTA / MA

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

Thn. Tamat.........................

B.2. Pendidikan Pesantren

1.

Nama pesantren

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

2.

Tempat Pesantren

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

3.

Tahun Masuk

: ...............................................Thn. Selesai.....................................................

4.

No. Ijazah/ Bukti Tamat Belajar (jika ada)

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

C. PENGUASAAN BAHASA ASING

1.

Bahasa Ingggris

: Baik / Sedang / Kurang **)

2.

Bahasa Arab

: Baik / Sedang / Kurang **)

3.

Lainnya (sebutkan)........................................................ : Baik / Sedang / Kurang **)

4.

...........................................................

: Baik / Sedang / Kurang **)

D. DATA ORANG TUA / WALI

1.

Nama Ayah

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

2.

Nama Ibu

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

3.

Nama Wali

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

4.

Pekerjaan Ayah

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

5.

Pekerjaan Ibu

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

6.

Pekerjaan Wali

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

7.

Hubungan dg Wali

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

*)

Nama harus lengkap (sesuai dengan ijazah)

Coret yang tidak perlu
**)
Coret yang tidak perlu.
**)

8.

Jml. Penghasilan Ayah

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

9.

Jml. Penghasilan Ibu

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

10. Pendidikan Ayah

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

11. Pendidikan Ibu

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

12. Alamat Rumah Orangtua

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

13. Alamat Wali

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

14. No. Tlp / HP

.........................................................................................................

D. LAIN-LAIN
1.

Karya Ilmiah / Penelitian

No.
1
2
3

2.

Tahun Terbit

Bentuk

Keterangan

Kursus / Pelatihan / Seminar

No.
1
2
3

3.

Judul Karya Imiah

Nama Kurus / Pelatihan / Seminar

Durasi

Penyelenggara

Tempat

Tahun

Pengalaman Kerja / Organisasi

No.
1
2
3

Bulan dan Tahun

Posisi

Nama Lembaga

........................................................., .........................................20.......
Photo Warna

Calon Mahasiswa,

3X4
(.............................................................)

Formulir pendaftaran wajib disertai lampiran-lampiran berikut:

1.

Photo Copy Ijazah SLTA sebanyak 2 lembar

2.

Bukti Lunas Pendaftaran

3.

Photo Warna Ukuran 3 X 4 = 2 lbr, dan 2 X 3 = 2 lbr