FORMULIR PENGAJUAN BEASISWA

UNIVERSITAS BINA DARMA

NAMA : _____________________________________________________________
NIM : _____________________________________________________________
TEMPAT & TGL LAHIR : _____________________________________________________________
FAKULTAS : _____________________________________________________________
PROG. STUDI : _____________________________________________________________
JENIS KELAMIN : _____________________________________________________________
ALAMAT : _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
NO. TELP/HP : _____________________________________________________________

DATA ORANG TUA

NAMA : _____________________________________________________________
ALAMAT : _____________________________________________________________
_____________________________________________________________
NO. TELP/HP : _____________________________________________________________
PEKERJAAN : _____________________________________________________________
PENGHASILAN/BULAN : _____________________________________________________________
JML TANGGUNGAN : _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
DATA LAMPIRAN
Fotocopy KTM
Fotocopy KHS
Fotocopy Rekening Listrik Terakhir
Fotocopy PBB
Foto 3x4
Fotocopy Buku Rekening Tabungan
Fotocopy Kartu Keluarga
Surat Keterangan Penghasilan Orang Tua
Surat Keterangan Kurang Mampu
Surat Permohonan Pengajuan Beasiswa.

Mengetahui, Mengetahui, Palembang,

Ka. Prog. Studi, Kepala Kemahasiswaan Mahasiswa

NB : SEMUA BERKAS DIFOTOCOPY RANGKAP 3 DAN DIMASUKAN DALAM MAP KERTAS KAMBING WARNA HIJAU