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 XL XXL

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