PROGRAM PASCASARJANA MAGISTER TERAPAN

(S2)

PROGRAM STUDI AGRIBISNIS

POLITEKNIK NEGERI JEMBER

Foto 4 x 6 (cm)

FORMULIR PENDAFTARAN
PROGRAM PASCASARJANA AGRIBISNIS (PPSA)
No. NUPTK : ..............................................

I. DATA PRIBADI
Nama Lengkap
(sesuai dengan ijazah D4 / S1)

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

Gelar Kesarjanaan

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

Tempat / Tanggal Lahir

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

Agama

: ................................................................................................ Jenis Kelamin : ( L / P )

Status Perkawinan

Alamat Rumah/Korespondensi

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

Menikah

Belum Menikah

Telp. ( ..............) .................................................. HP ...............................................................

Email : ...................... ...................................................................................................................
Alamat Kantor

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

Telp. ( ..............) ................................................. HP ...............................................................

Email : .........................................................................................................................................

II. LATAR BELAKANG AKADEMIK

Nama Perguruan Tinggi (D4 / S1)

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

Fakultas/Jurusan

: ....................................................................................... IPK : ...............................................

Pendidikan lain yang diperoleh

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

Penghargaan Akademik

: ................................................................................................................................................. .
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Kemampuan Bahasa Asing :

Bahasa (*)
membaca(*)
Berbicara(*)
Menulis(*)
1.
2.
3.
(*) Diisi dengan pilihan : SB= Sangat Baik; B= Baik; C= Cukup; K= Kurang

Formulir Pendaftaran Calon Peserta PPSA POLIJE

Hal 1 dari 6

Tes yang pernah diikuti

Jenis
TOEFL
GMAT
TPA

Tangal

Nilai

III. PENGALAMAN PEKERJAAN

(Khusus bagi yang sudah bekerja. Ditulis secara kronologis, bila diperlukan dapat menggunakan lembar tersendiri)

Nama Instansi

Jabatan

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Lama Kerja
Dari tahun

Sampai dengan tahun

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IV. MOTIVASI DAN HARAPAN

1.

Motivasi Saudara mengikuti Program PPSA POLIJE

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Formulir Pendaftaran Calon Peserta PPSA POLIJE

Hal 2 dari 6

2.

Karir apa yang akan Bapak/Ibu kembangkan setelah menyelesaikan Program PPSA POLIJE?

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V. REFERENSI
Tuliskan nama atasan Bapak/Ibu (bagi yang telah bekerja) dan/atau dosen pembimbing Bapak/Ibu yang dapat
memberikan rekomendasi untuk mendukung pendaftaran Bapak/Ibu. Untuk rekomendasi hendaknya dipergunakan
formulir yang telah disediakan.
Pemberi rekomendasi
Status

: Atasan

Nama Lengkap

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

Pekerjaan

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

Alamat Kantor

: .......................................................................................................... Telp. : ( ............... ) ............................

Pemberi rekomendasi
Status

: Dosen Pembimbing

Nama Lengkap

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

Pekerjaan

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

Alamat Kantor

: .......................................................................................................... Telp. : ( ............... ) ............................

VI. PERNYATAAN PELAMAR

Dengan ini kami mendaftarkan diri pada :
PROGRAM STUDI AGRIBISNIS
PROGRAM PASCASARJANA MAGISTER TERAPAN (S2) POLITEKNIK NEGERI JEMBER
dan formulir ini telah kami isi dengan jujur, benar dan lengkap.
Nama

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

Tanggal

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

Tandatangan :

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PROGRAM PASCASARJANA MAGISTER TERAPAN (S2)

PROGRAM STUDI AGRIBISNIS

POLITEKNIK NEGERI JEMBER

RAHASIA
PROGRAM PASCASARJANA MAGISTER TERAPAN (S2)
POLITEKNIK NEGERI JEMBER
SURAT REKOMENDASI
(Diperlukan untuk pendaftaran ke Program Studi Agribisnis POLIJE )

Pemberi Rekomendasi
Nama

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

Jabatan/Pangkat : ..................................................................................................................................
Nama Institusi

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

Alamat Kantor

: ................................................................................................................................. .
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Telp. (.............) ......................................................................................................

Calon Pendaftar
Nama

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

1. Sudah berapa lama Bapak/Ibu mengenal calon peserta, dan dalam hubungan apa ?
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2. Apakah menurut Bapak/Ibu calon peserta mempunyai kemampuan untuk mengikuti dan menyelesaikan Program
Pascasarjana Magister Terapan (S2) Program Studi Agribisnis di POLIJE ?
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3. Menurut pandangan Bapak/Ibu, dalam hal-hal apa calon peserta dianggap menonjol ?
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4. Dalam hal-hal apa Bapak/Ibu menganggap calon peserta memiliki kelemahan ?
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5. Gunakan pilihan berikut ini untuk menilai calon peserta (beri tanda silang pada peringkat yang saudara pilih)

Baik
sekali

Baik

Rata-Rata

Kurang

Tidak
dapat
menilai

Kemampuan analitik

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Kemampuan konseptual

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Komunikasi lisan

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Komunikasi tertulis

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Inisiatif

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Kesungguhan

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Kemandirian

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Kemampuan mengatur penggunaan waktu

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Peluang berhasil dalam studi

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Berdasarkan informasi diatas, (No. 5) saya merekomendasikan / tidak merekomendasikan

*) Calon yang bersangkutan.

Keterangan
*) Coret yang tidak perlu.

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Pemberi Rekomendasi

(..................................................................)

PROGRAM PASCASARJANA MAGISTER TERAPAN (S2)

PROGRAM STUDI AGRIBISNIS

POLITEKNIK NEGERI JEMBER

KELENGKAPAN PERSYARATAN
LAMARAN CALON PESERTA
1. Fotokopi ijazah dan transkrip nilai D 4 / S1 dari berbagai disiplin ilmu yang telah dilegalisir oleh
Perguruan Tinggi asal, masing-masing satu lembar.
2. Mengisi formulir pendaftaran secara lengkap dengan menyertakan pasphoto berwarna 4 x 6 cm (2
lembar).
3. Surat rekomendasi dari atasan dan/atau dosen pembimbing D4 / S1.
4.

Surat ijin / cuti belajar dari pimpinan instansi tempat calon peserta bekerja (bagi peserta kelas reguler yang
sedang bekerja).

5. Menyelesaikan biaya pendaftaran.

6. Mengikuti Tes Penerimaan (Tes Potensi Akademik).