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DATA MAHASISWA

FHOTO SEKOLAH TINGGI TEOLOGI BETHEL INDONESIA

A. DATA PRIBADI *
No. KTP : …………………………………………………………………………………………………………………….
Nama Lengkap : …………………………………………………………………………………………………………………….
Tempat dan Tgl. Lahir : …………………………………………………………………………………………………………………….
Jenis Kelamin : …………………………………………………………………………………………………………………….
Alamat : …………………………………………………………………………………………………………………….
Kelurahan : …………………………………………………………………………………………………………………….
Kecamatan : …………………………………………………………………………………………………………………….
Propinsi : …………………………………………………………………………………………………………………….
Jenis Tinggal : …………………………………………………………………………………………………………………….

No. Tlp. : …………………………………………………………………………………………………………………….


Email : …………………………………………………………………………………………………………………….
B. DATA IBU

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


Tempat dan Tgl. Lahir : .........................................................................................................................
Pendidikan : .........................................................................................................................
Pekerjaan : .........................................................................................................................
B. DATA AYAH

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


Tempat dan Tgl. Lahir : .........................................................................................................................
Pendidikan : .........................................................................................................................
Pekerjaan : .........................................................................................................................
Jakarta, ........................................

( .....................................................)

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