HIMPUNAN MAHASISWA PROGRAM STUDI

TEKNIK INFORMATIKA DAN SISTEM INFORMASI

FAKULTAS ILMU KOMPUTER
UNIVERSITAS TOMAKAKA MAMUJU
Jl. Ir. H. Djuanda No.77 Telp (0426) 22085 Mamuju

FORMULIR PENDAFTARAN
LATIHAN KEPEMIMPINAN MAHASISWA (LKM)
TAHUN AKADEMIK 2018/2019

1. Nama : ...................................................................................

2. Tempat/Tgl Lahir : ...................................................................................

3. Agama : ...................................................................................

4. Alamat : ...................................................................................

5. Jurusan : ...................................................................................

6. Contact Person (CP)

Peserta : ...................................................................................

Orang Tua : ...................................................................................

7. Minat dan Bakat : ...................................................................................

8. Moto Hidup : ...................................................................................

9. Alasan Mengikuti LKM : ...................................................................................

10. Penyakit Yang Pernah Diderita : ...................................................................................

11. Pengalaman Organisasi : ...................................................................................

Mamuju, November 2018

FOTO Peserta

3x4

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