1. Nama lengkap : ...............................................................
2. Tempat, tanggal lahir : ............................................................... 3. Agama : ............................................................... 4. Suku bangsa : ............................................................... 5. Asal Panda / No. Daerah : ............................................................... 6. Tinggi badan / berat badan : ............................................................... 7. Alamat calon : ............................................................... (kode pos & Nomor telepon) : ............................................................... 8. Asal sekolah (SMU / sederajat) : ............................................................... a. Status : Negeri/Disamakan/Diakui/Terakreditasi*) b. Jurusan : ............................................................... c. Tahun Lulus : ............................................................... d. NUS dan NUN terendah : ............................................................... e. Rata rata Nilai Akhir : ............................................................... f. Nilai akhir Matematika : ............................................................... 9. Pernah mendaftar TNI AU : ............................................................... (sampai tingkat pusat) : ............................................................... 10.Nama Ayah / pekerjaan : ............................................................... (pangkat & kesatuan) : ............................................................... 11.Nama Ibu / pekerjaan : ............................................................... (pangkat & kesatuan) : ............................................................... 12.Alamat orang tua : ............................................................... (kode pos & Nomor telepon) : ............................................................... 13.Nama wali / Pekerjaan : ............................................................... (kode pos & nomor telepon) : ............................................................... 14.Alamat wali : ............................................................... (kode pos & nomor telepon) : ............................................................... ............... , .............................. 20…. Yang bersangkutan/Pelamar
............................................ Catatan : 1. Tulis dengan huruf balok/kapital 2. Lingkari yang sesuai. *)