STT WIWOROTOMO

PURWOKERTO

FORMULIR WISUDAWAN UNTUK YUDISIUM

Wisuda Tanggal :

Nama : ..................................................................................................

No. Mahasiswa : ..................................................................................................

Program Studi : ..................................................................................................

Terdaftar Tanggal (D3/S1) : ..................................................................................................

Lulus Tanggal : ..................................................................................................

Lama Studi : ..................................................................................................

IPK : ..................................................................................................

Toefl : ..................................................................................................

SKS : ..................................................................................................

Purwokerto,
Wisudawan/Wisudawati

( ....................................................)
 DATA PENULISAN IJAZAH S-1/D-III

HARAP DIKETIK

Nama : .............................................................................................

(diisi sesuai ijazah SLTS Non Transfer/Diploma-3 Untuk transfer)

Nomor Mahasiswa : .............................................................................................

(diisi lengkap sesuai kartu mahasiswa)

Program Studi : .............................................................................................

Tempat Lahir : .............................................................................................

Tanggal Lahir : .............................................................................................

Tanggal ujian Ujian TA/Skripsi : .............................................................................................

Nama Gelar Diploma : .............................................................................................

Alamat sekarang : .............................................................................................

No. Telepon rumah/HP/E-mail : .............................................................................................

Tanda tangan
Calon Wisudawan

Pas Foto 3 x 4 Pas Foto 3 x 4

Berwarna Hitam Putih
Tempel sedikit Tempel sedikit
saja saja

(......................................................)

KETERANGAN
Agar dilampiri fotokopi:
1. Ijazah SLTA/Diploma yang sudah dilegalisir
2. Kartu Mahasiswa S1/DIII
 STT WIWOROTOMO
PURWOKERTO

FORMULIR DATA WISUDAWAN/WISUDAWATI DIPLOMA 3/SARJANA

Wisuda Tanggal : ....................................................

HARAP DIKETIK
Nama(dengan gelar D-3/S1) : ..................................................................................................
NIM : ..................................................................................................
Tempat & Tanggal lahir : ..................................................................................................
Kawin / Belum kawin : ..................................................................................................
Agama : ..................................................................................................
Nomor Mahasiswa : ..................................................................................................
Program Studi D-3/S-1 : ..................................................................................................
Terdaftar Tanggal (D3/S1) : ..................................................................................................
Lulus Tanggal (D3/S1) : ..................................................................................................
Asal D-3 & Tahun : PROGRAM STUDI :............................... Lulus Tahun : ............
Universitas/Sekolah Tinggi/Akademi/Poltek :.................................
Pekerjaan sekarang **) : ..................................................................................................
Alamat rumah tetap : ..................................................................................................
Nama Orang Tua *) : ..................................................................................................
Pekerjaan Orang Tua : ..................................................................................................
Alamat Orang Tua : ..................................................................................................
Judul Skripsi : ..................................................................................................
..................................................................................................
..................................................................................................
Pembimbing Utama : ..................................................................................................
No. Tlp./E-mail : ..................................................................................................

Purwokerto, .........................

Pas Foto 3 x 4 Wisudawan / Wisudawati

Berwarna
Tempel sedikit
saja

..............................................

KETERANGAN
*) Apabila sudah meninggal agar ditambah kata (Alm.)
**) Harap disebutkan instansinya
 FORMULIR PENDAFTARAN ANGGOTA KELUARGA ALUMNI
STT WIWOROTOMO PURWOKERTO
(ILUNI STT WIWOROTOMO PURWOKERTO)

HARAP DIKETIK :
Nama :
Nomor Mahasiswa :
Tempat dan Tanggal Lahir :
Lulus D-III /Sarjana Tanggal :
Alamat tetap :
Alamat Pekerjaan :
Nama Orang Tua/Wali :
Alamat Orang Tua/Wali :
No. Telpon Rumah / HP :
Email/ Whatsapp/BBM/ Facebook :

(Harap memberitahu bila pindah alamat)

Dengan menyerahkan /membayar : a. Uang Pangkal Rp. 115.000,-
b. Uang Pandel Rp. 100.000,-
c. Uang Lencana Rp. 35.000,-
Jumlah Rp. 250.000,-
d. 2 lembar pas foto ukuran 3x4 cm
Mengetahui : Purwokerto, ............................
Kaprodi .............................................. Tanda tangan,
STT WIWOROTOMO

( ....................................................... ) ( ................................. )

Pas Foto Pas Foto

2x3 2x3
Harap ditempel Harap ditempel
Sedikit saja Sedikit saja

(Berwarna) (Berwarna)

NB :
 Background foto untuk lulusan Semester Genap berwana Biru dan Ganjill berwarna Merah
 Bagi calon wisudawan/wati yang sebelumnya sudah menyelesaikan studi di STT WIWOROTOMO,
harap disebutkan asal ijasah, berikut tanggal wisuda:
 Asal Ijasah : Tanggal :
Diploma Wisuda
 DATA PENULISAN IJAZAH DAN TRANSKRIP

HARAP DIKETIK

Nama : .............................................................................................

(diisi sesuai ijazah SLTS Non Transfer/Diploma-3 Untuk transfer)

Nomor Mahasiswa : .............................................................................................

(diisi lengkap sesuai kartu mahasiswa)

Program Studi : .............................................................................................

Tempat Lahir : .............................................................................................

Tanggal Lahir : .............................................................................................

Tanggal ujian Ujian TA/Skripsi : .............................................................................................

Nama Gelar Diploma : .............................................................................................

Alamat sekarang : .............................................................................................

No. Telepon rumah/HP/E-mail : .............................................................................................

Tanda tangan
Calon Wisudawan

Pas Foto 4 x 6 Pas Foto 4 x 6

Hitam Putih Hitam Putih
Tempel sedikit Tempel sedikit
saja saja

(......................................................)

Pas Foto 3 x 4 Pas Foto 3 x 4

Hitam Putih Hitam Putih
Tempel sedikit Tempel sedikit
saja saja

KETERANGAN
Agar dilampiri fotokopi:
1.Ijazah SLTA/Diploma yang sudah dilegalisir
2.Kartu Mahasiswa S1