FORMULIR PENDAFTARAN

Panitia Penerimaan Taruna Baru Tahun 2011

SEKOLAH TINGGI PERIKANAN JAKARTA
Jln. AUP No.1 Pasar Minggu - Jakarta Selatan (12520)
Telp. 021-7805030, 7806874, 78830275 Fax : 021-7805030, 78830275

Photo
4x6

Nomor Pendaftaran (diisi oleh Panitia)

Yang bertanda tangan di bawah ini :

(1) Nama : ................................................................................................................................... (02) Kelamin :

Lk

Pr
(3) Tempat lahir : ................................................................................................... Tgl-Bln-Tahun

Kota..................................................................Kab/Kotamadya...............................
Propinsi ................................................
(4) Status :

Calon dari umum

(5) Agama :

Islam

Calon dari PNS

Kristen

Katolik

Hindu

Budha

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

(6) Asal Sekolah :

SMU/Jurusan : ........................................................................................................ Tahun Lulus
SMK/SUPM/Jurusan : ........................................................................................... Tahun Lulus
(7) Nama Sekolah :..................................................................................................................
(8) Alamat Sekolah : ..............................................................................................................
Kota:................................................................. Kab/Kotamadya:.............................................
Propinsi:.............................................
(9) Melamar menjadi taruna STP, pada program studi :
Pilihan 1 :

TPI

MP

TPH

TAK

TPS

PP

Pilihan 2 :

TPI

MP

TPH

TAK

TPS

PP

(10) Alamat
Rumah : ................................................................................................................................................................
Kota:................................................................. Kab/Kotamadya:.............................................
Propinsi:.............................................
Telp : .....................................................
HP:.....................................................Email:...................................................................................

(11)

Pekerjaan Orang tua :

PNS

TNI/POLRI

Wiraswasta Perikanan

Tani

Nelayan

Pengolah Ikan
Pembudidaya Ikan

Pedagang Ikan

Petani Garam

Wiraswasta lainnya

sebutkan:......................................................................
Bersama ini saya lampirkan :
1 lembar copy ijasah/STTB/Surat Tanda Lulus yang disyahkan Kepala Sekolah;
2 lembar pas photo terbaru ukuran 4 x 6 (berwarna);
1 lembar copy Surat Keterangan Catatan Kepolisian;
1 lembar copy Surat Keterangan belum menikah dari Kepala Desa/Lurah (calon dari umum);
1 lembar copy Kartu Keluarga;
Surat ijin Belajar dari Pimpinan instansi/unit kerja, copy DP3 terakhir dan copy SK Kepegawaian terakhir
(calon dari PNS)
copy bukti transfer Uang Pendaftaran Rp. 75.000,- (tujuh puluh lima ribu rupiah) yang ditransfer ke rekening
0147374582 Bendahara Penerimaan STP, Bank BNI 46 Cabang Fatmawati Jakarta;
...................................................................
2011
Panitia Pendaftaran

Pendaftar

Nama Jelas

Nama Jelas

Formulir Pendaftaran Jalur Umum | 1 dari 3

Catatan Petugas :
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DAFTAR ISIAN PESERTA

CALON TARUNA SEKOLAH TINGGI PERIKANAN TAHUN 2011
PETUNJUK : Isilah pertanyaan di bawah ini (38 pertanyaan), secara lengkap sesuai dengan keadaan yang
sebenarnya. Jika tidak cukup dapat mengisi pada bagian halaman belakang.

KETERANGAN PRIBADI:

(1)

Nama Lengkap (sesuai ijazah) :

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

(2)

Nama Panggilan

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

(3)

Anak ke :

: ................................................... dari ......................

bersaudara

(4)

Golongan Darah
: ..........................................................................................................................................................
..................

(5)

Agama

(6)

Telp/HP

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

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

(7)

Email : .........................................................................................................................................

(8)

Tempat
Lahir : .........................................................................................................................................
Kota:.................................................................
Kab/Kotamadya:............................................................. Propinsi:.............................................

(9)

Status

(10)

Asal instansi (untuk calon dari

Calon dari umum

Calon dari PNS

PNS) : .................................................................................................................................................
................
(11)

Alamat
instansi : ............................................................................................................................................
..............................................................

(12)

Asal Sekolah :
SMU Jurusan : ...................................................................................................... Tahun Lulus :

Formulir Pendaftaran Jalur Umum | 2 dari 3

SMK/SUPM Jurusan : ........................................................................................ Tahun Lulus :

(13)

Nama
Sekolah : ............................................................................................................................................
....................................................................

(14)

Alamat
Sekolah : ............................................................................................................................................
.................................................................
Kota:.................................................................

Kab/Kotamadya:............................................................... Propinsi:.............................................
(15)

Hobby : ..............................................................................................................................................
.................................................................................

(16)

(17)

Melamar menjadi Taruna STP, pada program studi :

Pilihan 1 :

TPI

MP

TPH

TAK

TPS

PP

Pilihan 2 :

TPI

MP

TPH

TAK

TPS

PP

Alamat
Rumah : ........................................................................................................................................
Telp : .........................................................
Kota:................................................................. Kab/Kotamadya:.............................................

Propinsi:.............................................
(18)

Daya listrik :

watt

KETERANGAN KELUARGA
Ayah

(19) Nama : ...............................................................................................................................................

.................................................................................
(20)

Pendidikan
Terakhir : ............................................................................................................................................
.....................................................

(21)

Pekerjaan : .........................................................................................................................................
...............................................................................

(22)

Penghasilan Per Tahun :

(23)

Alamat tempat

< 10 jt

10 15 jt

16-20 jt

21-25 jt

> 25 jt

kerja : .................................................................................................................................................
...............................................
Telp/Fax : ......................................................... HP: .....................................................................
Email : ................................................................

Ibu
(24)

Nama : ...............................................................................................................................................
.................................................................................

(25)

Pendidikan
Terakhir : ............................................................................................................................................
.....................................................

(26)

Pekerjaan : .........................................................................................................................................
...............................................................................

(27)

Penghasilan Per Tahun :

Formulir Pendaftaran Jalur Umum | 3 dari 3

< 10 jt

10 15 jt

16-20 jt

21-25 jt

> 25 jt

(28)

Alamat tempat
kerja : .................................................................................................................................................
...............................................
Telp/Fax : ......................................................... HP: .....................................................................
Email : ................................................................

Formulir Pendaftaran Jalur Umum | 4 dari 3

Wali di Jakarta
(29)

Nama : ...............................................................................................................................................
.................................................................................

(30)

Pendidikan
Terakhir : ............................................................................................................................................
.....................................................

(31)

Pekerjaan : .........................................................................................................................................
...............................................................................

(32)

Alamat
Rumah : .............................................................................................................................................
.................................................................
Telp/Fax : ......................................................... HP: .....................................................................
Email : .................................................................

(33)

Alamat tempat
kerja : .................................................................................................................................................
..................................................
Telp/Fax : ...........................................................................................................................................
................................................................................

(34) Data Saudara Kandung:

No

Nama

Tgl Lahir/Umur

Pekerjaan

Keterangan
(Menikah/Belum
Menikah)

Laman
ya
.....s/d..
...

Tempat

Penyelenggar
aan

Sertifikat
(ada/tdk ada)

Laman
ya
.....s/d..
...

Tempat

Kedudukan
dalam
Organisasi

Pimpinan
Organisasi

Kelami
n (L/P)

(35) Kursus/Pelatihan yang pernah diikuti:

No

Nama Kursus/Pelatihan

(36) Organisasi yang pernah diikuti:

No

(37)

Nama Organisasi

Prestasi/Penghargaan yang pernah diraih:

Formulir Pendaftaran Jalur Umum | 5 dari 3

No

(38)

Nama Kursus/Pelatihan

Laman
ya
.....s/d..
...

Tempat

Penyelenggar
aan

Sertifikat
(ada/tdk ada)

Dalam keadaan darurat, Siapa yang bisa dihubungi?

Nama : ...............................................................................................................
Hubungan dengan yang bersangkutan :................................................................................... Telp
: .............................................................
Alamat : .............................................................................................................................................
..................................................................................
Demikian data ini dibuat dengan sebenarnya untuk dapat digunakan sebagaimana mestinya.

____________________________________________
(Nama Jelas dan Tanda Tangan)

Formulir Pendaftaran Jalur Umum | 6 dari 3