PROGRAM PASCASARJANA
Kampus Universitas Negeri Jakarta, Jl. Rawamangun Muka, Jakarta Timur 13220. Telp. (021) 4721340, Fax. 4897047
Website: www.ppsunj.org email : tu@ppsunj.org
Laki Laki
Perempuan
() ceklist salah
satu
4. Alamat Rumah
5.
6.
7.
8.
9.
: ........................................................................
.................................................................
Kode
Pos :
Telepon Rumah
: . HP : .......
Latar Belakang Pendidikan S1 ....................................................
a. Jurusan / Program Studi : ........................................................................
b. Tanggal Lulus
: ........................................................................
c. Nama Perguruan Tinggi : ........................................................................
d. Propinsi Asal
: ........................................................................
e. IPK dan Beban Studi
:
.
/
SKS
Latar Belakang Pendidikan S2
a. Jurusan / Program Studi : ........................................................................
b. Tanggal Lulus
: ........................................................................
c. Nama Perguruan Tinggi : ........................................................................
d. Propinsi Asal
: ........................................................................
e. IPK dan Beban Studi
:
.
/
SKS
Data Administratif
a. Pekerjaa / Jabatan **)
: ........................................................................
b. Instansi Tempat Bekerja : ........................................................................
Khusus Dosen *)
- Nama Perguruan Tinggi : ........................................................................
- Fakultas
: ........................................................................
- Jurusan
: ........................................................................
- Bidang Keahlian
: ........................................................................
c. Alamat Kantor
: ........................................................................
.................................................................
Kode
Pos :
d. Telepon / Fax Kantor
: ........................................................................
Lampiran
a.
b.
c.
d.
Jakarta, ......
*) Wajib
**) Pekerjaan : PNS/Swasta/lain, sebutkan!
Jabatan Dosen/Guru
Sebutkan Tetap atau Tidak Tetap
...........
(Tanda