NAMA :……………………………………………………………………….
TTL :……………………………………………………………………….
TLP/HP/PIN :……………………………………………………………………….
:……………………………………………………………………….
JURUSAN………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
REGESTRASI : Rp 50.000,-
………………………………………..
Nama & TTd.