SEKOLAH TINGGI AGAMA ISLAM

AL HIKMAH TUBAN
SK Dirjen Pendidikan Islam Nomor : Dj.I/362/2010
Terakreditasi SK BAN-PT Nomor: 242/SK/BAN-PT/Ak-XVI/S/XII/2013
PP Al Hikmah Binangun Singgahan Tuban Jawa Timur 62361
Telp: 0811 3275 666 E-mail : staialhikmahtuban79@gmail.com

FORMULIR PENDAFTARAN MAHASISWA BARU

TAHUN AKADEMIK …………… / ……………

Pilihan Prodi :

Manajemen Pendidikan Islam (MPI) Ekonomi Syariah (ES)

Pendidikan Guru Madrasah Ibtida’iyah (PGMI) Hukum Keluarga/Ahwal Syakhsiyah (AS)
Pendidikan Islam Anak Usia Dini (PIAUD) Perbankan Syari’ah (PS)

I. Mahasiswa

1. Nama Mahasiswa : _________________________________________________________________________________

2. Tempat Lahir : _________________________________________________________________________________
3. Tanggal Lahir : _________________________________________________________________________________
4. Jenis Kelamin : _________________________________________________________________________________
5. Agama : _________________________________________________________________________________
6. Status Mahasiswa : reguler non reguler
7. NISN : _________________________________________________________________________________
8. NIK : _________________________________________________________________________________
9. Alamat
Jalan : _________________________________________________________________________________
Dusun : _________________________________________________________________________________
RT/RW : _________________________________________________________________________________
Desa, Kec., Kab. : _________________________________________________________________________________
Kode Pos : _________________________________________________________________________________
Provinsi : _________________________________________________________________________________
Jenis Tinggal : Rumah Sendiri Ikut Ortu Asrama / kontrak
10. Telp. : _________________________________________________________________________________
11. Email : _________________________________________________________________________________
12. Sekolah Asal : _________________________________________________________________________________
13. Tahun Lulus : _________________________________________________________________________________

II. Orang Tua/Wali

14. Nama Ayah : _________________________________________________________________________________

TTL : _________________________________________________________________________________
Pendidikan : _________________________________________________________________________________
Pekerjaan : _________________________________________________________________________________
Agama : _________________________________________________________________________________
NIK : _________________________________________________________________________________
15. Nama Ibu : _________________________________________________________________________________
TTL : _________________________________________________________________________________
Pendidikan : _________________________________________________________________________________
Pekerjaan : _________________________________________________________________________________
Agama : _________________________________________________________________________________
NIK : _________________________________________________________________________________
16. Alamat
Jalan : _________________________________________________________________________________
Dusun : _________________________________________________________________________________
RT/RW : _________________________________________________________________________________
Desa, Kec., Kab. : _________________________________________________________________________________
Kode Pos : _________________________________________________________________________________
Provinsi : _________________________________________________________________________________

Nb : Biodata ini harus di isi dengan valid dan benar (sesuai penulisan ijazah).