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FORMULIR PENDAFTARAN

MASA AWAL BIMBINGAN MAHASISWA BARU (MABIM)

FAKULTAS KEDOKTERAN UNSWAGATI TAHUN 2017

Nama Lengkap : .....................................................................................

Nama Panggilan : .....................................................................................

Tempat, Tanggal Lahir : .....................................................................................

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

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

Alamat Rumah : .....................................................................................

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Alamat Kost : .....................................................................................

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Hobi : .....................................................................................

Ukuran Pakaian : .....................................................................................

No. Telepon : .....................................................................................

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

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

Nama Ayah : .....................................................................................

Pekerjaan Ayah : .....................................................................................

Nama Ibu : .....................................................................................

Pekerjaan Ibu : .....................................................................................


Alamat Orang Tua : .....................................................................................

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No. Telepon Orang Tua : .....................................................................................

Motivasi Masuk Kedokteran :...................................................................................

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

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……………., ………… 2017

Foto Mahasiswa bersangkutan,

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