Anda di halaman 1dari 1

HIMPUNAN MAHASISWA ARSITEKTUR

INSTITUT TEKNOLOGI NASIONAL MALANG


JALAN BENDUNGAN SIGURA – GURA NO.2, RUMAH SINGGAH ARSITEKTUR
GEDUNG UKM / HMJ Lt.2 MALANG
Email : hma.itnmalang1@gmail.com No. HP 085604026952

FORMULIR PENDAFTARAN
PESERTA ARCHDAYS 2018

Nama : ...............................................................................................................................

NIM : ...............................................................................................................................

Jurusan : ...............................................................................................................................

Tempat & Tanggal Lahir : ...............................................................................................................................

Alamat di Malang : ...............................................................................................................................

No. Telp (Hp) : ...............................................................................................................................

Organisasi yang pernah diikuti : .................................................................................................................

Riwayat Penyakit : 1. .......................................................................

2. .......................................................................
Pas Foto

3x4
Syarat – syarat pendaftaran :

1. Menyerahkan pas foto 3 x 4 (2 lmbr).


2. Membayar uang sebesar Rp.

Malang,......................... 2018

........................................................

Anda mungkin juga menyukai