Pas foto berwarna

ukuran 6x4 cm

FORMULIR DJARUM BEASISWA PLUS

Petunjuk :
1. Bacalah setiap pertanyaan dengan seksama dan istilah dengan huruf cetak
2. Berikan keterangan yang sesuai dengan keadaan yang sebenarnya
A. IDENTITAS
Nama Lengkap

: ...........................................................................L/P*)

Tempat/tanggal Lahir

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

No.HP

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

Alamat Asal/Orang Tua

: ...............................................................................
..............................................................................
RT/ RW : ............. Telp : ........................................

Alamat Sekarang/Kontrak/Kost : ................................................................................

...............................................................................
RT/ RW : ............. Telp : ........................................
Alamat E-mail

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

Alamat Facebook

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

Perguruan Tinggi / PT

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

Kota / Alamat PT

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

Fakultas

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

Jurusan

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

Semester

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

NIM

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

IPK Semester III

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

IPK Semester IV

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

Ukuran Baju

: S , M , L , XL , XXL , XXXL *)

B. KELUARGA
Susunan Keluarga

Orang Tua
Ayah

Ibu

Nama
Usia
Pendidikan
Alamat

No.Telp

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

Anak ke..........................dari .......................saudara

Saudara Kandung
Nama

Usia

L/P Pendidikan

Pekerjaan

C. PENDIDIKAN
Dasar dan Menengah
Tingkat Nama Sekolah

Kota

Tahun

Lulus/Tidak

Nilai

SD
SMP
SMU
Kursus/Training/Seminar
Topik

Penyelenggara

Tahun

Keterangan

*) Lampirkan Fotocopy : Serifikat / ijazah / Tanda lulus

Penguasaan Bahasa Asing
Bahasa

Tertulis
Kurang

Cukup

Lisan
Baik

Kurang

Cukup

Baik

D. MINAT
Apakah anda sedang menerima beasiswa lain? [ ] Tidak

[ ] Ya

Mengapa Anda berminat untuk mendaftar dalam Beasiswa Djarum?.................................

...................................................................................................................................
Apakah yang anda ketahui tentang Beasiswa Djarum?.....................................................
...................................................................................................................................
...................................................................................................................................
Apakah yang anda ketahui tentang Djarum....................................................................
...................................................................................................................................
Bersediakan anda untuk aktif dalam kegiatan Beasiswa Djarum?
[ ] Tidak [ ] Ya
Berikan alasannya?........................................................................................................
....................................................................................................................................
....................................................................................................................................
Apakah anda tertarik dengan kegiatan sosial? [ ] Tidak

[ ] Ya

Berikan alasannya?........................................................................................................
....................................................................................................................................
Jika anda tertarik dengan kegiatan sosial,jelaskan bentuk kegiatan sosial yang anda sukai?
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Bagaimana sikap anda jika mendapatkan tawaran dari beasiswa lain?...............................
....................................................................................................................................
....................................................................................................................................
Sebutkan keterampilan khusus yang dikuasai?................................................................
...................................................................................................................................
...................................................................................................................................
Sebutkan hobby atau kegemaran saudara?.....................................................................
...................................................................................................................................
...................................................................................................................................

E. AKTIFITAS SOSIAL DAN KEGIATAN LAIN

Apakah anda tertarik mengikuti kegiatan diluar jam kuliah? [ ] Tidak

[ ] Ya

Jika Ya, kegiatan diluar kuliah apa yang paling menarik untuk diikuti dan mengapa?
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Jika Tidak, kenapa tidak tertarik untuk mengikuti kegiatan diluar kuliah?
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
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1. Kegiatan Dalam Kampus
Nama
Organisasi/Kegiatan

Jabatan

Waktu
Keikutsertaan

Alasan Mengikuti

2. Kegiatan Di Luar Kampus

Nama
Organisasi/Kegiatan

Jabatan

Waktu

Alasan Mengikuti

Keikutsertaan

3. Apakah anda mempunyai pekerjaan sampingan/part time?

Jika Ya, sebagai apa?...............................................................................................
..............................................................................................................................

Semua keterangan yang saya tuliskan pada formulir ini telah sesuai dengan keadaan
yang sebenarnya.

................................,...............

,
nama jelas

Interview : ................................
Catatan :

Tgl: .............................................