Keluarga Mahasiswa Bidikmisi

(KAMADIKSI)
Universitas Diponegoro
​ niversitas Diponegoro
Sekretariat: Gedung ​Student Center U
Semarang, Jawa Tengah

FORMULIR PENDAFTARAN VOLUNTEER

KELUARGA MAHASISWA BIDIKMISI (KAMADIKSI) UNIVERSITAS DIPONEGORO
PERIODE 2014

Data Pribadi
Nama Lengkap : ..............................................................................................................
Nama Panggilan : ....................................................... Jenis Kelamin : L / P
Tempat/Tanggal Lahir : ..............................................................................................................
Agama : ..............................................................................................................
Alamat Rumah : ..............................................................................................................
..............................................................................................................
Alamat Kos : ..............................................................................................................
..............................................................................................................
Nomor Handphone : ..............................................................................................................
Email : ..............................................................................................................
Hobi : ..............................................................................................................
Golongan Darah : ..............................................................................................................

Riwayat Pendidikan
SD : ...................................................................................... Periode : ..................................
SMP : ...................................................................................... Periode : ..................................
SMA : ...................................................................................... Periode : ..................................
Program Studi : ...................................................................................... Angkatan : ..............................
NIM : ......................................................................................

Nama Orang Tua :

Ayah : ..................................................... Pekerjaan : ................................................................
Ibu : ..................................................... Pekerjaan : ................................................................
Jumlah Saudara : .......................................................................
 Keluarga Mahasiswa Bidikmisi
(KAMADIKSI)
Universitas Diponegoro
Sekretariat: Gedung ​Student Center ​Universitas Diponegoro
Semarang, Jawa Tengah

Aktivitas Keorganisasian (selama 6 tahun terakhir)

Aktivitas Keorganisasian yang pernah / sedang diikuti

Nama Organisasi Jabatan Lingkup Periode

Pelatihan / Pendidikan Non Formal Yang Penah / Sedang Diikuti :

Institusi Jenis Pendidikan/Pelatihan Periode

Kemampuan / Keahlian Pribadi yang Dimiliki :

1. ................................................................................ 4. ...........................................................................
2. ................................................................................ 5. ...........................................................................
3. ................................................................................ 6. ...........................................................................

Fasilitas yang Dimiliki

4. ................................................................................ 4. ...........................................................................
5. ................................................................................ 5. ...........................................................................
6. ................................................................................ 6. ...........................................................................

Prestasi yang Pernah Diraih (Akademis / Non Akademis)

1. ................................................................................................................................................................
2. ................................................................................................................................................................
3. ................................................................................................................................................................
4. ................................................................................................................................................................
 Keluarga Mahasiswa Bidikmisi
(KAMADIKSI)
Universitas Diponegoro
Sekretariat: Gedung ​Student Center ​Universitas Diponegoro
Semarang, Jawa Tengah

Buku Yang Pernah Dibaca dan Berkesan (Tulis Judul Beserta Pengarangnya):
1. ................................................................................................................................................................
2. ................................................................................................................................................................
3. ................................................................................................................................................................

Harian / Majalah / Tabloid yang Sering Dibaca :

7. ................................................................................ 4. ...........................................................................
8. ................................................................................ 5. ...........................................................................
9. ................................................................................ 6. ...........................................................................

Motivasi untuk Mendaftarkan diri sebagai volunteer Kamadiksi Undip 2014 :

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

Apa yang akan Anda Lakukan di Kamadiksi Undip 2014 :

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

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

Bidang yang dipilih (Beserta Alasan) :

*Lingkari Salah Satu Kementrian yang anda Minati Beserta divisinya

1. Bidang Kesmasos
2. Bidang Kewirausahaan
3. Bidang Minat dan Bakat
4. Bidang Pengabdian Masyarakat
5. Bidang Pengembangan Sumber Daya Manusia
6. Bidang Riset
7. Bidang Media Informasi
 Keluarga Mahasiswa Bidikmisi
(KAMADIKSI)
Universitas Diponegoro
Sekretariat: Gedung ​Student Center ​Universitas Diponegoro
Semarang, Jawa Tengah

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“Demikian formulir ini saya isi dengan sebenar-benarnya dan tanpa paksaan daripihak
manapun. Dengan ini saya mendaftarkan diri saya sebagai Volunteer Kamadiksi Undip periode
2014 dan berjanji siap mengabdi serta menanggung segala konsekuensi yang berkenaan
dengannya”

Semarang, ……………………………..

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Tanda Tangan dan Nama Lengkap