KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS NAHDLATUL ULAMA PURWOKERTO

(UNU PURWOKERTO)
Jln. Sultan Agung No 42, Karangklesem, Purwokerto Selatan, Purwokerto, Jawa Tengah, 53144
Telp/Faks. (0281) 6841836; e-mail: unupurwokerto@gmail.com; website: http://www.unupurwokerto.ac.id

FORMULIR PENDAFTARAN MAHASISWA BARU

(DIISI DENGAN HURUF KAPITAL)

1. No. Pendaftaran

2. Nama : .............................................................................................................................................
3. Tempat Lahir : .............................................................................................................................................
4. Tanggal Lahir : .............................................................................................................................................
5. Jenis Kelamin : Laki - laki Perempuan Agama : ............................................
6. NIK : .............................................................................................................................................
7. No. KK : .............................................................................................................................................
8. Alamat Rumah : .............................................................................................................................................
Nama Dusun : .............................................................................. RT/RW:............................................
Kelurahan : .............................................................................................................................................
Kecamatan : .............................................................................................................................................
Kabupaten : .............................................................................. Kode Pos: .......................................
9. Jenis Tinggal : Bersama Orang tua Wali Kost Asrama lainya .......................

11. Nomor WhatsApp (WA)/HP : .............................................................................................................................................

12. Email : .............................................................................................................................................
13. Terima KPS : BPJS Askes Asuransi lainya .......................
No. KPS : .............................................................................................................................................
14. Ayah Ibu Wali
Nama
Tanggal lahir
Pendidikan Terakhir
Pekerjaan
Penghasilan

15. No. HP Orang Tua : .............................................................................................................................................

16. Pilihan Prodi kesatu : .............................................................................................................................................
Pilihan Prodi kedua : .............................................................................................................................................
Pilihan Prodi ketiga : .............................................................................................................................................
17. Kelas : Kelas Pagi (07.30 s/d 16.45) Kelas Malam (15.30 s/d 23.00)
18. Asal Sekolah : SMA / SMK / MA /......................................................................................................
Alamat Sekolah : .............................................................................................................................................
Tahun Lulus : .............................................................................................................................................
Jurusan Sekolah : .............................................................................................................................................
Purwokerto: ..............................................
Nama & Paraf Petugas Pendaftar

................................................................. .................................................................
 No. Pendaftaran (diisi oleh petugas)
 Berilah tanda √ (centang) pada kotak pilihan yang sesuai