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POLITEKNIK NEGERI SRIWIJAYA

Himpunan Mahasiswa Jurusan Teknik Elektro


Alamat: Jalan Srijaya Negara Bukit Besar Palembang 30139
Website hmj_elektro.polsri.ac.id, E-mail : Hmj_elektro@gmail.com

Formulir & Curriculum Vitae


Bakal Calon Pengurus HMJ Teknik Elektro 2017

1. Nama : Elizabeth Panggabean


2. Tempat/Tgl.Lahir : Palembang/ 24 Juni 1999
3. Jenis Kelamin : Perempuan
4. Agama : Kristen Protestan
5. Hobi : Menyanyi
6. Gol. Darah :A
7. Alamat Sekarang : Jln. Pasundan lrg. Nyiur 1 No. 247 RT 34 RW 07
8. No.Telp/HP : 083178463423
9. Jurusan/Semester : Teknik Telekomunikasi/ Semester 1
10. Kelas : 1 TD
11. Jumlah Saudara :Laki-laki 1 /Perempuan 3
12. Riwayat Pendidikan :
a. Pendidikan Formal
1. SD.........................................................................Lulus Tahun................................
2. SMP......................................................................Lulus Tahun................................
3. SMA................................ .....................................Lulus Tahun................................
b. Pendidikan Non Formal
1...................................................................................Tahun.........................................
2...................................................................................Tahun.........................................

13. Pengalaman Organisasi (Intra Sekolah atau Intra Kampus)


1.....................................Sebagai..................................Tahun........................................
2.....................................Sebagai..................................Tahun........................................

14. Pengalaman Organisasi (Ekstra Sekolah atau Ekstra Kampus)


1.....................................Sebagai..................................Tahun........................................
2.....................................Sebagai..................................Tahun........................................

15. Keahlian :...............................................................................................................


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16. Aktivitas Selain Kuliah :


1...............................................Berapa Jam......................Pada Hari..............................
Contact Person :
Bayu Sugara : 082179410568
M. Miftahul Rohman : 082236981957
POLITEKNIK NEGERI SRIWIJAYA
Himpunan Mahasiswa Jurusan Teknik Elektro
Alamat: Jalan Srijaya Negara Bukit Besar Palembang 30139
Website hmj_elektro.polsri.ac.id, E-mail : Hmj_elektro@gmail.com

2...............................................Berapa Jam......................Pada Hari..............................

17. Kegiatan/Acara yang akan dilakukan bila menjadi Pengurus HMJ Elektro 2017
1.................................................................................................................................
2.................................................................................................................................

18. Bidang yang dipilih : 1..........................................................................................


2..........................................................................................

Orang Tua
Nama Ayah/Ibu : /
Tempat/Tgl.Lahir : /
Pendidikan Terakhir : Ayah :
Ibu :
Alamat Orang Tua :....................................................................................................
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Pekerjaan : Ayah: Ibu:

Fasilitas yang dimiliki :


1. Telepon/HP 5. Motor
2. Kamera Digital 6. Mobil
3. Komputer 7. Handy Cam
4. Laptop/Notebook 8. Lain-lain............................................
(*wajib diisi dan lingkari fasilitas yang dimiliki)

SIAP BERKOMITMEN DENGAN HMJ TEKNIK ELEKTRO 2017 : YA / TIDAK


(*coret)

Alasan ingin menjadi pengurus HMJ TEKNIK ELEKTRO 2017 :


.........................................................................................................................................
Contact Person :
Bayu Sugara : 082179410568
M. Miftahul Rohman : 082236981957
POLITEKNIK NEGERI SRIWIJAYA
Himpunan Mahasiswa Jurusan Teknik Elektro
Alamat: Jalan Srijaya Negara Bukit Besar Palembang 30139
Website hmj_elektro.polsri.ac.id, E-mail : Hmj_elektro@gmail.com

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Motto :.......................................................................................................................
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VISI :......................................................................................................................
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MISI :......................................................................................................................
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Palembang, 2017

4x6
warna

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NIM...................................................

AUTOBIOGRAFI

Contact Person :
Bayu Sugara : 082179410568
M. Miftahul Rohman : 082236981957
POLITEKNIK NEGERI SRIWIJAYA
Himpunan Mahasiswa Jurusan Teknik Elektro
Alamat: Jalan Srijaya Negara Bukit Besar Palembang 30139
Website hmj_elektro.polsri.ac.id, E-mail : Hmj_elektro@gmail.com

*Ditulis tangan dan boleh lebih 1 lembar

Contact Person :
Bayu Sugara : 082179410568
M. Miftahul Rohman : 082236981957