PANITIA PELAKSANA ORIENTASI PENGENALAN ALAM

(OSPAL X)
HIMPUNAN MAHASISWA BIOLOGI
FAKULTAS KEGURUAN DAN ILMU PENDIDIKAN
FOTO WARNA
UNIVERSITAS SYIAH KUALA
3X4 cm
2 Lembar

Sekretariat : Laboratorium Biologi FKIP Unsyiah Darussalam 23111 Telp. 53180-53977 Pos. 23111

BIODATA MAHASISWA
A. IDENTITAS PRIBADI
Nama Mahasiswa

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

NIM

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

TTL

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

Telp

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

B. STATUS MAHASISWA
Terdaftar Sebagai Mahasiswa: Undangan/SPMB/Biaya/Beasiswa/TID
Bekerja

: Belum/Sudah*)

Kawin

: Belum/Sudah*)

Biaya Pendidikan

C. KETERANGAN KELUARGA
Jumlah Saudara Kandung

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

Anak Ke

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

Yang Sudah Sarjana

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

Sedang Kuliah

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

D. KETERANGAN ORANG TUA/WALI

AYAH
Nama

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

Tempat/Tanggal Lahir

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

Pendidikan Terakhir

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

Pekerjaan

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

Penghasilan Per Bulan

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

Alamat

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

Telp/hp

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

IBU
Nama

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

Tempat/Tanggal Lahir

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

Pendidikan Terakhir

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

Pekerjaan

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

Penghasilan Per Bulan

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

Alamat

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

Telp/hp

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

Darussalam,
September 2010
Mahasiswa Ybs,

Mengetahui:
Ketua HIMABIO,
E. KETERANGAN KESEHATAN
Tinggi Badan
AFKAR
Berat Badan

: ................................................................................
(??????????...?..)
NIM
: ................................................................................

Penyakit Yang Diderita

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

Golongan Darah

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

F. RIWAYAT PENDIDIKAN
No
1.
2.
3.
4.

Nama sekolah

NEM

Tahun Lulus

Nama Organisasi

Jabatan

Tahun

Kegiatan

Peringkat

Tahun

G. PENGALAMAN ORGANISASI
No
1.
2.
3.
4.
5.
H. PRESTASI
No
1.
2.
3.
4.
5.
I. LAIN - LAIN
Agama

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

Jenis Kelamin

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

Alamat

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

Bakat/Minat

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

Motto

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

*) Coret yang tidak perlu

Tulis dengan huruf balok
C/HIMABIO/Biodata Mahasiswa