Form PPs No.

01

PROGRAM PASCASARJANA
UNIVERSITAS ANDALAS

Tempelkan
Pasfoto
(tick your
photograph here)

Gedung E, Kampus Limau Manis

Po Box. 271 Padang 25163
Telp. (0751) 71686, Fax. (0751) 71691
E-mail : pps-and@telkom.net

4x6 cm

PERMOHONAN MENJADI MAHASISWA

PADA PROGRAM PASCASARJANA UNIVERSITAS ANDALAS
(Diisi dengan huruf balok/diketik)

APPLICATION FORM
(Fill in with block letter or type it)

Untuk Pelamar

(For the applicant)

Pengisian formulir lamaran menjadi mahasiswa ini dilengkapi dengan :

(The application form should be completed with)
Fotocopy Ijazah (dilegalisir) (legalized certificate of undergraduate study)

1.
2.
3.
4.

5.
6.
7.
8.
9.

Fotocopy Transkrip (dilegalisir) (legalized academic transcript)

Pasfoto ukuran 4x6 (3 lembar) (3 pieces of photograph 4x6)
Surat Rekomendasi Kelayakan Akademik (2 orang untuk S2, 3 orang untuk S3)

(Letter of recommendation from two persons for Master, and from 3 persons for PhD)
Surat Keterangan Dokter (asli) (original copy of physician)

Karya Ilmiah (scientific works)

Surat Izin Atasan (bagi yang sudah bekerja) (letter of permission from office headman)
Bukti Pembayaran Biaya Pendaftaran (slip of registration fee)
Khusus Pelamar Program S3, harus melampirkan rancangan awal penelitian
(Disertasi).

I. Identitas Pribadi (personal data)

:____________________________________________________

1.1. Nama Lengkap (name)

1.2. Tempat/Tgl. Lahir

(place/date of birth):____________________________________________________

1.3. Jenis Kelamin (sex)

: Lk/Pr* (M / F ), Status Perkawinan

1.4. Alamat Tetap

:____________________________________________________

(permanent address)

(marital status):

____________

________________________ Telp : ______________________

Alamat di Padang (address in Padang) :____________________________________________________
_______________________ Telp : ______________________
II.

Riwayat Pendidikan dan Pelatihan (Education and Training history)

2.1. Perguruan Tinggi

(universities)

Nama dan Tempat Perguruan

Tinggi (name and place of the

Program Studi/
Mayor (study

universities)

program or major)

-1-

Masuk

(year of
enrolled)

Lulus

(year of
graduation)

IPK

Gelar

(GPA)

(Degree)

Form PPs No. 01

2.2. Pelatihan yang pernah diikuti

(Trainings)

Nama Pelatihan (name of trainings)

III.

Instansi (institution)

Bahasa

Alamat (address)

Jabatan (position)

Keterangan (others)

Aktif/Pasif

Kualifikasi (Baik/Sedang/Buruk)

(active or passive)

Qualification (excellent/good/bad)

Penghargaan Akademik yang Pernah Diperoleh (honors or reputations)

Tahun (year)

VI.

Keterangan (others)

Penguasaan Bahasa Asing (foreign language proficiency)

(language)

V.

Lama (duration)

Riwayat Pekerjaan (working experiences)

Tahun (year)

IV.

Tempat (place)

Nama Penghargaan (name of honors)

Instansi yang Memberikan (institutions)

Publikasi Ilmiah/Buku yang Diterbitkan (scientific publications)

Tahun (year)

Judul (title

Penerbit (publishers)

VII. Pendaftaran yang diinginkan (registration for) :

6.1. Tahun ajaran

(enrollment year).

6.2. Kelas Reguler/Khusus*

Semester .

(regular or executive class)

6.3. Program Magister (S2)/Doktor (S3)*

(Master or PhD program)

-2-

Form PPs No. 01

Program Studi
Pemusatan

(study program)

(specific concentration)

:
:

..

VIII. Biaya Pendidikan (dilingkari) (Educational support, choose one)

a. Biaya sendiri
b. BPPS
c.

(government educational scholarship)

Beasiswa dari (sponsored by)

(lampirkan surat persetujuan) (enclosed the approval letter)

d. Lain-lain
IX.

(personal budget)

(others)

___________________________________

Pemberi Rekomendasi (Persons who give the recommendation)

No.

Nama (name)

Alamat (address)

Jabatan (position)

Tanda Tangan (signature)

____________________________
Tanggal
* Coret yang tidak perlu (give a cross for not chosen field)

-3-

(date):

________________

Form PPs No. 01

EVALUASI PROGRAM STUDI

The Evaluation of the Study Program

[ ] Direkomendasikan

(recommended)

[ ] Diterima sebagai mahasiswa penuh

[ ] Diterima dengan percobaan

(full acceptance)

(accepted with some requests)

[ ] Ditolak/belum dapat diterima

(not accepted)

CATATAN EVALUATOR (note from the evaluator)

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Ketua Program Studi

Program Studi

(Chairman of the study program)

(the Study Program)

..

(..)
DIREKTUR PROGRAM PASCASARJANA
(Director of the Graduate Program)

[ ] Disetujui untuk

(approval for):

[ ] Diterima penuh

(full acceptance)

[ ] Diterima dengan percobaan

[ ] Ditolak

(accepted with some requests)

(not accepted)

_______________________________
D I R E K T U R (Director)

Tanggal (date): _______________________

-4-