PANITIA PELAKSANA PENGAKTIFAN KORPS SUKARELA (KSR)

PMI POLITEKNIK KESEHATAN KEMENKES PALEMBANG

FORMULIR PENDAFTARAN
KORPS SUKARELA (KSR) PMI
POLTEKKES KEMENKES PALEMBANG
IDENTITAS PRIBADI
Nama Lengkap : ..............................................................................................

Tempat/Tanggal Lahir : ..............................................................................................

Alamat : ..............................................................................................

Agama : ..............................................................................................

Jenis Kelamin : ..............................................................................................

Jurusan/Prodi : ..............................................................................................

No.Telp/WA : ..............................................................................................

Asal Sekolah : ..............................................................................................

Tinggi/Berat Badan : Cm/ Kg Gol.Darah A/ B/ AB/ O

Hobby : ..............................................................................................

Motto Hidup : ..............................................................................................

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Alasan Masuk KSR : ..............................................................................................

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IDENTITAS ORANG TUA

Nama Ayah : ...............................................................................................
Pendidikan Ayah : ................................................................................................
Pekerjaan : ................................................................................................
Nama Ibu : ................................................................................................
Pendidikan Ibu : ................................................................................................
Pekerjaan : ................................................................................................
Alamat Orang Tua : ................................................................................................
No.Telp/WA : ...............................................................................................
 PANITIA PELAKSANA PENGAKTIFAN KORPS SUKARELA (KSR)
PMI POLITEKNIK KESEHATAN KEMENKES PALEMBANG

Visi Untuk KSR : ................................................................................................

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Misi Untuk KSR : ................................................................................................

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Prestasi Akademik 1. ................................................................................................

2. ................................................................................................

3. ................................................................................................

Prestasi Non Akademik 1. ................................................................................................

2. ...............................................................................................

3. ...............................................................................................

Riwayat Organisasi 1. ................................................................................................

2. ................................................................................................

3. ................................................................................................

Saya yang bertanda tangan dibawah ini menyatakan bahwa data yang saya cantumkan
adalah benar dan dengan ini saya menyatakan bersedia untuk mengikuti,mentaati serta
mematuhi ketentuan dan peraturan yang berlaku.

Palembang, November 2018

Pas Photo
3x4
(Berwarna) .....................................................
NIM.