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FORMULIR PENDAFTARAN

RESIMEN MAHASISWA (MENWA)


UNIVERSITAS KHAIRUN TERNATE

1. NamaMahasiswa : ........................................................................................................
2. NIM/Fak/Jur : ........................................................................................................
3. Alamat/No. Hp (telp) : ........................................................................................................
4. Tempat, tanggallahir : ........................................................................................................
5. Agama : ........................................................................................................
6. Hobby : ........................................................................................................
7. Asal SMU : ........................................................................................................
8. PengalamanOrganisasi: ........................................................................................................
9. Data Orang Tua
a) Nama Orang Tua :..................................................................................................
b) Alamat : ...........................................................................................................
c) Pekerjaan : ...........................................................................................................
10. Sinyalemen
a) Tinggi/Berat : .......................
b) GolonganDarah : .......................
c) Mata : (bulat/oval/sipit) / (hitam/coklat) *
d) Rambut : (lurus/ikal/keriting) *

DenganinisayasiapdansanggupuntukmendaftarkandirisebagaicalonanggotaResimen
MahasiswaUniversitasKhairun Ternate.

Ternate, ……………………2018
HormatSaya,

Foto 3 x 4

(…………………….)

Catatan :

1. Melampirkanfotokopy KTM ( 2 lembar)


2. Foto 3X4 (3lembar)
3. Suratijin orang tua
4. Surat keterangan sehat dokter (tidak memiliki penyakit dalam & pernah mengalami
kecelakaan/operasi besar)
* :coret yang tidakperlu

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