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FORMULIR PENDAFTARAN ONLINE SBMPTN 2018

POSKO PENDAFTARAN SBMPTN


HIMPUNAN MAHASISWA JURUSAN KIMIA FMIPA UHO
EMAIL : TELP :

BIODATA
NAMA PESERTA (SESUAI IJAZAH) : _______________________________________________________
NAMA PESERTA (UNTUK LJU) : _______________________________________________________
NOMOR INDUK SISWA NASIONAL (NISN) : _______________________________________________________
ALAMAT TETAP : _______________________________________________________
PROVINSI : _______________________________________________________
KABUPATEN KOTA : _______________________________________________________
KODE POS : _______________________________________________________
TELP./HP. : _______________________________________________________
EMAIL : _______________________________________________________
PROVINSI TEMPAT LAHIR : _______________________________________________________
KABUPATEN/KOTA LAHIR : _______________________________________________________
TEMPAT TANGGAL LAHIR (TTL) : _______________________________________________________
JENIS KELAMIN : _______________________________________________________
AGAMA : _______________________________________________________
KEWARGANEGARAAN : _______________________________________________________
JUMLAH SAUDARA
ADIK : _______________________________________________________
KAKAK : _______________________________________________________
NAMA AYAH/WALI : _______________________________________________________
NAMA IBU : _______________________________________________________
PENDIDIKAN ORANG TUA/WALI
AYAH : _______________________________________________________
IBU : _______________________________________________________
PEKERJAAN ORANG TUA/WALI
AYAH : _______________________________________________________
IBU : _______________________________________________________
PENGHASILAN
AYAH : _______________________________________________________
IBU : _______________________________________________________
KEBUTUHAN FASILITAS KHUSUS : _______________________________________________________
DATA PENDIDIKAN
NAMA SMTA : _______________________________________________________
JURUSAN SMTA : _______________________________________________________
PROVINSI SMTA : _______________________________________________________
KABUPATEN/KOTA : _______________________________________________________
TAHUN MASUK SMTA : _______________________________________________________
TAHUN LULUS SMTA : _______________________________________________________
DATA PILIHAN
LOKASI UJIAN : _______________________________________________________
PILIHAN 1
PTN/PRODI : _______________________________________________________
PILIHAN 2
PTN/PRODI : _______________________________________________________
PILIHAN 3
PTN/PRODI : _______________________________________________________
*HARAP ISI DENGAN BENAR

KWITANSI PEMBAYARAN
NOMER :
TELAH TERIMA DARI : _________________________________________________________________________
UANG SEJUMLAH : _________________________________________________________________________
RP.
UNTUK PEMBAYARAN :_________________________________________________________________________
____________________________________________________________________________________________
________________________________
PENERIMA :

*HARAP DIBAWA SAAT PENGAMBILAN KARTU UJIAN (_______________________________)

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