BASTEK GROUP

BASMEN TEKNOLOGI GROUP

UNIVERSITAS TEKNOLOGI YOGYAKARTA
Sekretariat : Jl Ringroad Utara, Jombor, Yogyakarta Telp : 085643291096, 085291856313

FORMULIR PENDAFTARAN ARISAN LAPTOP

(Diisi menggunakan huruf KAPITAL)
A. DATA UMUM
1. Nama Lengkap
2. Nomor Mahasiswa
3. Fakultas / Jurusan
4. Perguruan Tinggi
5. Alamat Asal

:
:
:
:
:

6. Alamat Tinggal
7. Agama
8. Tempat, Tanggal Lahir
9. Alamat e-mail / HP
B.

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: ...................................................................................................................
...................................................................................................................
: ............................................ Golongan Darah : ..................................
: ...................................................................................................................
: ............................................ Jenis Kelamin
: ..................................

DATA KELUARGA
1. Nama Ayah / Ibu
2. Nama Wali
3. Alamat Orang Tua
4.
5.
6.
7.
8.

: ...................................................................................................................
: ...................................................................................................................
: ...................................................................................................................
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Alamat Wali
: ...................................................................................................................
...................................................................................................................
Pekerjaan Orang Tua
: Ayah
: ................................... Ibu : .........................................
Wali
: ..............................................................................................
Jumlah Saudara Kandung: ...................................................................................................................
Jumlah Saudara Tiri
: ...................................................................................................................
Anda Anak ke
: ...................................................................................................................

Pas Foto

Pas Foto

3x4

3x4

Yogyakarta,
PEMOHON

2012

( __________________________ )

Catatan:
1. Surat ini sewaktu-waktu dapat dialihkan kepada Pimpinan Perguruan Tinggi untuk diproses secara
Hukum.
2. Formulir dapat diperbanyak sesuai kebutuhan.
3. Dengan mengisi Formulir ini berarti anda menyetujui sarat dan ketentuan yang berlaku.