FORMULIR PENDAFTARAN OSCAR IAI IBRAHIMY 2019

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

Nama Panggilan : ....................................................................................................
Tempat, tanggal lahir : ....................................................................................................
4 X6
Jenis Kelamin : L / P (*) PHOTO
Alamat Rumah Asal : ....................................................................................................
RT/ RW...................Kode Pos.....................................................
Alamat di Banyuwangi : ....................................................................................................
No Telp / HP : ....................................................................................................
Golongan Darah : : ....................................................................................................
Agama : ...................................................................................................
Anak ke : ……….. dari ………. Bersaudara
Alamat Email : ..................................................................................................
Facebook / Twitter : ..................................................................................................
Ukuran Kaos : ..................................................................................................
Hobi : ..................................................................................................
Motto Hidup : ..................................................................................................
Cita-cita : ..................................................................................................
Tokoh Idola : ..................................................................................................
Fakultas : ..................................................................................................
Jurusan / Prodi : ..................................................................................................
NIM : ..................................................................................................
Riwayat Penyakit : ..................................................................................................
Makanan Pantangan : ..................................................................................................
Alergi : ..................................................................................................
Pengalaman Mistis : ..................................................................................................
 Riwayat Pendidikan
No Jenjang Intitusi Tempat Tahun Lulus
1 SD
2 SMP/Mts
3 SMA/MA
4
Pengalaman Organisasi
No Nama Organisai Jabatan Tempat Priode
1
2
3
4
Prestasi Yang Pernah Dicapai
No Prestasi Tingkat Tempat Tahun
1
2
3
4

Data Orang tua/ Wali

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

Alamat : ...............................................................................................................

No HP : ...............................................................................................................

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

Pekerjaan : ...............................................................................................................

Alamat : ..............................................................................................................

No HP : ...........................................................................................................

Banyuwangi, .....-.....- 2019

Hormat saya,

……………………………
NIM.
 SURAT PERNYATAAN
KESANGGUPAN MENGIKUTI KEGIATAN OSCAR
TAHUN 2019
Yang bertanda tangan di bawah ini :
Nama : ......................................................................................................

NIM : ......................................................................................................

Jurusan / Fakultas : ......................................................................................................

Nama Perguruan Tinggi : ......................................................................................................

Alamat e-mail : ......................................................................................................

No. Handphone : ......................................................................................................

Dengan ini meyatakan :

1. Bersedia / tidak bersedia *) mengikuti kegiatan OSCAR pada tahun 2019.
2. Bersedia / tidak bersedia *) melaksanakan peraturan OSCAR tahun 2019.
Demikian surat pernyataan ini dibuat dan ditanda tangani dengan penuh kesadaran dan tanpa
paksaan dari siapapun.
Banyuwangi,.....-....,2019
Yang Membuat Pernyataan

Materai Rp. 6.000,-

(________________________)
Keterangan : *) coret yang tidak perlu