Formulir Pendaftaran

Program Beasiswa Sarjana S1

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NamaLengkap

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

TempatLahir

:.....................................................................TanggalLahir..................................

JenisKelamin

: Lakilaki Perempuan

AlamatSurat

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

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Kota:........................................................................KodePos:.........................

Telepon:....................................Handphone:...................................................

Email

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

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

NomorKTP

LatarBelakangPendidikan
Isidenganlatarbelakangpendidikan
NamaSMA

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

Kota

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

TahunMasuk

:...............................TahunLulus:...............................

BidangStudi

: IPA IPS Bahasa Lainnya...............................

NilaiRatarataUAN

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

Universitas

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

Fakultas

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

ProgramStudi

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

TahunMasukUniversitas

:...................IPKAkhirSemGenap:...................

PrestasiNonAkademik/Sosial
Isidenganprestasiyangpalingakhir/Jnggidiraih(mendapatpiagam/bukJpenghargaan)
Level

NamaInsJtusi

: Kecamatan Kota/Kabupaten Propinsi Nasional

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

FormulirProgramBeasiswaSarjanaS1

TahunDiterima

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

Deskripsi

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

KondisiEkonomi
Isidengankondisiekonomikeluarga
SaatiniandaJnggaldi?

: Rumahsendiri Denganorangtua

Dengansaudara Kontrak/Kos

ApakahandamemilikitanggungjawabuntukmenaSahikeluarga?

PendapatanpribadiseJapbulan

: Ya Tidak
:Rp........................................................

PengeluaranpribadiseJapbulan :Rp........................................................
KosseJapbulan

TagihanListrikrumahorangtua

:Rp........................................................
:Rp........................................................

Kendaraanyangdimilikiolehorangtua

Mobil Motor

RiwayatKeluarga
Isidenganriwayatkeluargaanda

DataAyah
NamaAyah

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

TanggalLahir

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

AlamatSurat

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

.......................................................................................................................

Kota:....................................................KodePos:.................................

Telepon:.....................................Handphone:.....................................

PendidikanTerakhir

: SMAataudibawahnya

S1 S2 S3

Pekerjaan

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

Status

: Bekerja Tidakbekerja Sudahmeninggal

Pendapatanbersihperbulan

:Rp........................................................

DataIbu
NamaIbu

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

TanggalLahir

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

AlamatSurat

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

FormulirProgramBeasiswaSarjanaS1

.......................................................................................................................

Kota:....................................................KodePos:.................................

Telepon:.....................................Handphone:.....................................

PendidikanTerakhir

: SMAataudibawahnya

S1 S2 S3

Pekerjaan

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

Status

: Bekerja Tidakbekerja Sudahmeninggal

Pendapatanbersihperbulan

:Rp........................................................

Jumlahsaudarakandungyangmasihmenjaditanggunganorangtua

:............orang

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diskualikasi dan penghentian sebagai Peserta Program Beasiswa S1.
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Tanggal :......................................................................

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