Nomor :
I. KHUSUS
1. Nama : ....................................................................................................
2. Nomor BP : ....................................................................................................
3. Tempat / Tgl. Lahir : ........................................../.........................................................
4. Jenis Kelamin : ....................................................................................................
5. Agama : ....................................................................................................
6. Fakultas : ....................................................................................................
7. Jurusan / Prog. Studi : ........................................../.........................................................
8. Semester ke : ....................................................................................................
9. Negeri Asal : ....................................................................................................
10. S t a t u s : Belum kawin / kawin / janda / duda *)
11. Pekerjaan : Mhs. Reguler / Mhs. Non-Reguler / PNS / Peg. Swasta *)
12. No. HP : ...................................................................................................
13. Alamat Email : ..................................................................................................
II. U M U M
III. LAIN-LAIN
Padang, ....................20...
Saya yang mendaftar,
Catatan :