NAMA
: _________________________________
NIM/ NIS
: _________________________________
ALAMAT
: _________________________________
_________________________________
NAMA BANK
: _________________________________
NO.REKENING
: _________________________________
a.n.______________________________
( Lampirkan fotocopy buku rekening pribadi )
UNIV/ SMK
: _________________________________
: _________________________________
E MAIL
: _________________________________
NO. HP
: _________________________________
PALEMBANG,
YANG BERSANGKUTAN,
20
Agt/April16