FORMULIR PENDAFTARAN OPAK 2019

IAIN Lhokseumawe

BIODATA PESERTA

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

No. Ujian : ......................................................................................................................
Fakultas : ...................................................................................................................... 3x4
Jurusan : ......................................................................................................................
Tempat/Tgl. Lahir : ......................................................................................................................
JenisKelamin : Laki – Laki Perempuan

Alamat : ..................................................................................................................................................
No. HP : ..................................................................................................................................................
Email : ..................................................................................................................................................
Hobby : ..................................................................................................................................................
Ukuran Baju* : *Beri Tanda Silang (X) Sesuai Ukuran S M L XXL
XL

I. Jenjang Pendidikan
1. SD : ............................................................................................................................................
2. SMP : ............................................................................................................................................
3. SMA : ............................................................................................................................................
II. Pengalaman Organisasi
1. . .......................................................................................................................................................................
2. . .......................................................................................................................................................................
3. . .......................................................................................................................................................................
III. Prestasi Yang Pernah Di Raih
1. . .......................................................................................................................................................................
2. . .......................................................................................................................................................................
3. . .......................................................................................................................................................................
IV. Motto Hidup
..............................................................................................................................................................................
..............................................................................................................................................................................

Lhokseumawe, 2019

( NamadanTandaTangan )

Note :
1. Menyerahkan Foto Copy Slip PembayaranOpak, Serta Memperlihatkan Slip Yang Asli
2. Menyerahkan Fas Photo Warna :
- Laki– LakiLayarBiru
- PerempuanLayarMerah
3 x 4 = 2 lembar
4 x 6 = 1 lembar
( Bagi Perempuan Wajib Berjilbab)
3. Pengembalian Formulir pada waktu daftar ulang mahasiswa baru