FORMULIR PENDAFTARAN ANGGOTA BARU

UNIT KEGIATAN MAHASISWA

UNIVERSITAS PADJADJARAN

 Identitas Diri
Nama :________________________________________________________________________
NPM :________________________________________________________________________
Fakultas :________________________________________________________________________
Jurusan :________________________________________________________________________
TTL :________________________________________________________________________
Alamat
Kost :________________________________________________________________________
Tempat Tinggal Asal :________________________________________________________________________
No Hp :________________________________________________________________________
Akun Media sosial :________________________________________________________________________
Line, FB dll
 Identitas Orang Tua
Nama Ayah :________________________________________________________________________
Nama Ibu :________________________________________________________________________
Pekerjaan :________________________________________________________________________
Alamat :________________________________________________________________________
No Hp/Telephon :________________________________________________________________________
Alamat :________________________________________________________________________
 Alasan Mengikuti UKM Merpati Putih Universitas Padjadjaran:
________________________________________________________________________________________________
________________________________________________________________________________________________
 Prestasi yang Pernah Diraih:
1._______________________________________________________________________________________________
2._______________________________________________________________________________________________
3._______________________________________________________________________________________________
 Organisasi yang Diikuti Sekarang:
1._______________________________________________________________________________________________
2._______________________________________________________________________________________________
3._______________________________________________________________________________________________
 Riwayat Penyakit yang Pernah Diderita:
1._______________________________________________________________________________________________
2._______________________________________________________________________________________________
 Riwayat Pendidikan
Jenjang Pendidikan Tahun Masuk Tahun Lulus