KEMENTERIAN AGAMA RI

INSTITUT AGAMA ISLAM NEGERI (IAIN)

SYEKH NURJATI CIREBON
PUSAT TEKNOLOGI INFORMASI DAN PANGKALAN DATA (PTIPD)
Alamat : Jl. Perjuangan Ny Pass Sunyaragi Cirebon 45132 Telp. (0231) 481264 Faks. (0231) 489926
Website : www.syekhnurjati.ac.id

FORMULIR PENGAJUAN DATA ALUMNI KE PDDIKTI

BIODATA MAHASISWA
Nama : .............................................................................................................................
Nama Ibu : .............................................................................................................................
Tempat/tgl Lahir : .............................................................................................................................
Jenis Kelamin : .............................................................................................................................
Agama : .............................................................................................................................
Kewarganegaraan : .............................................................................................................................
Jalan : .............................................................................................................................
Kelurahan : ................................... Kecamatan : ...................................................................
Telepon/HP/Email : .............................................................................................................................
HISTORY PENDIDIKAN
Jenjang Jenis Tanggal Perguruan
No NIM Periode Program Studi
Pendidikan Pendaftaran* Masuk Tinggi
1

Keterangan :
*Diisi Peserta Didik Baru/ Pindahan

PERKULIAHAN DAFTAR MAHASISWA LULUS/ DROP OUT

1) NIM/Nama : ..................................................................................................................................
Jenis Keluar : ..................................................................................................................................
Tanggal Keluar : ..................................................................................................................................
Jalur Skripsi : Skripsi/Non Skripsi**(Coret yg tidak Perlu)
Judul Skripsi : ..................................................................................................................................
..................................................................................................................................
Dosen Pemb. : ..................................................................................................................................
IPK : ..................................................................................................................................
No. Seri Ijazah : ..................................................................................................................................

2) NIM/Nama : ..................................................................................................................................
Jenis Keluar : ..................................................................................................................................
Tanggal Keluar : ..................................................................................................................................
Judul Tesis : ..................................................................................................................................
..................................................................................................................................
IPK : ..................................................................................................................................
No. Seri Ijazah : ..................................................................................................................................

Cirebon,.................................2018
Pemohon,

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