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 :