POLITEKNIK KESEHATAN TANJUNGKARANG

BADAN EKSEKUTIF MAHASISWA (BEM)

UNIT KEGIATAN MAHASISWA (UKM) ISLAM AL-KINDI
Sekretariat: Jl. Soekarno-Hatta No.1 Bandar Lampung 35144 Telp. 082279007770 (Vergit Nicola) 082182748215 (Hadi Imam P.)
082373518773 (Nabila Husnun F.)

FORMULIR PENDAFTARAN
UNIT KEGIATAN MAHASISWA (UKM) ISLAM AL-KINDI
POLTEKKES TANJUNGKARANG

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

NIM : ..............................................................................................................
Prodi/Jurusan : ..............................................................................................................
Jenis Kelamin : ..............................................................................................................
Tempat & Tanggal lahir : ..............................................................................................................
Alamat Rumah Asal : ..............................................................................................................
Alamat Rumah Sekarang : ..............................................................................................................
E-mail : ..............................................................................................................
Nomor Telp/ HP/WA : ..............................................................................................................
Kemampuan Khusus :

Desan grafis Computer skill

Publik Speaking Entrepreneurial

Creativity Lainnya :
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*centang pada pilihan

Jenis Departemen Yang Diminati :

1. Departemen PPSDA 4. Departemen Dana dan Usaha

2. Departemen Syi’ar 5. Departemen Sosial

3. Departemen Kemuslimahan 6. Departemen Al-Qur’an dan Hadist
*lingkari nomor pilihan ; maksimal memilih 2 departemen

Motivasi/Alasan Masuk UKMI Al-Kindi dan memilih Depertemen tersebut

Motto Hidup : ..............................................................................................................

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Pengalaman Organisasi : 1. ..............................................................................................................
2. ..............................................................................................................
3. ..............................................................................................................
TEMPEL FOTO 3 X 4
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Pemohon,

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