BIODATA MAHASISWA

PERGURUAN TINGGI : UNIVERSITAS LAMPUNG

FAKULTAS : KEDOKTERAN
JURUSAN/PRODI (S-1) : PENDIDIKAN DOKTER
TAHUN ANGKATAN : 2019 4 x 6 cm
berwarna

I. IDENTITAS MAHASISWA
Nama Mahasiswa : ..............................................................................
Nomor Pokok Mahasiswa (NPM) : ........................................
No. Telp./ HP :...............................................................................
Jenis Kelamin : LAKI-LAKI/ PEREMPUAN *)
Masuk Melalui Jalur : .......................................
Agama : ......................................
Kebangsaan : INDONESIA /........................................
Tempat, (Tgl, bln,Th) Lahir : ................................................................
Golongan Darah : A / AB / B / O **)

Hobby : ....................................................
Anak yang ke .......dari sejumlah.... : ....................................................
Status Anak : Kandung / Angkat / lainnya (............................) *)
Status Pernikahan : Sudah menikah / Belum Menikah *)
Alamat tempat tinggal (asal daerah) : ..................................................................
: ...................................................................
: ...................................................................

Alamat Kost Saat ini : ..............................................................................

: ...............................................................................
: ...............................................................................

: ...............................................................................
 II. DITERIMA SEBAGAI MAHASISWA.
Pada tanggal : .................................2019
Status Mahasiswa : BARU / PINDAHAN *)
Asal Sekolah : .........................................................................
No. Telp. Sekolah : .........................................................................
Alamat Sekolah :............................................................................
:............................................................................
:............................................................................
Ijazah SLTA terakhir : ........................................
Tahun Ijazah : ........................................

III. IDENTITAS ORANG TUA/ WALI :

A. Nama Ayah / Wali *) : .................................................................
No. Telp. / HP. : ...............................................................................
Umur : ..................Tahun
Alamat Rumah :................................................................................
................................................................................
...............................................................................
Pekerjaan : .....................................................................
Instansi : ..............................................................................
No. Telp. Instansi : ..............................................................................
Alamat Instansi : ..............................................................................
...............................................................................
...............................................................................
Penghasilan Utama (1.A.) : Rp ..................................................
Penghasilan lain-lain (2.A) : Rp ..................................................
Jumlah Penghasilan A (1.A + 2.A): Rp ....................................................
 B. Nama Ibu / Wali *) : ..............................................................................
No. Telp. / HP. : ...............................................................................
Umur : ..............Tahun
Alamat Rumah :................................................................................
................................................................................
...............................................................................
Pekerjaan : .....................................................................
Instansi : ..............................................................................
No. Telp. Instansi : ..............................................................................
Alamat Instansi : ..............................................................................
...............................................................................
...............................................................................

Penghasilan Utama (1.B.) : Rp ..................................................

Penghasilan lain-lain (2.B) : Rp ..................................................

Jumlah Penghasilan B (1.B + 2.B) : Rp ...................................................

C. Jumlah Penghasilan C (A+B) : Rp ....................................................

IV. BESAR UKT : Rp ....................................................

KELAS
Catatan : *) Coret yang tidak perlu.
**) lingkari yang sesuai
: 1 / 2 / 3 / 4 / 5 /6 / 7 / 8 / 9 **)
Bandar Lampung, .................................2019
Yang membuat,

...................................................
NPM