FORMULIR PENDAFTARAN

RESIMEN MAHASISWA SATUAN 901/PD

UNIVERSITAS DIPONEGORO
YUDHA XLI

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

2. NIM/Fak/Jur : ..............................................................................................
..........
3. Alamat : ..............................................................................................
..........
4. No. Hp (telp)
: ........................................................................................................
5. Tempat, tanggal lahir
: ........................................................................................................
6. Agama : ..............................................................................................
..........
7. Hobby : ..............................................................................................
..........
8. Asal SMU
: ........................................................................................................
9. Pengalaman Organisasi
: ........................................................................................................
10. Data Orang Tua
a) Nama Orang Tua : ...........................................................................................................
b) Alamat : ...........................................................................................................
c) Pekerjaan : ...........................................................................................................
d) No. Hp (Telp) : ...........................................................................................................
11. Sinyalemen
a) Tinggi/Berat : .......................
b) Golongan Darah : .......................
c) Mata : (bulat/oval/sipit) / (hitam/coklat) *
d) Rambut : (lurus/ikal/keriting) *
12. Motivasi
Alasan :.........................................................................................................
.............................................................................................................................................. ....
..........................................................................................................................................
13. Apakah saudara siap dan sanggup menyediakan perlengkapan latihan
(seragam/sepatu/kopel/ransel)?
Alasan :.........................................................................................................
......................................................................................................................................
Dengan ini saya siap dan sanggup untuk mendaftarkan diri sebagai calon anggota Resimen
Mahasiswa Mahadipa Satuan 901/PD Undip.

Semarang,…………………2017
Hormat Saya,

Foto 3 x 4
 (…………………….)

Catatan :
1. Melampirkan foto kopy KTM ( 2 lembar)
2. Foto 3X4 (3 lembar)
3. Surat ijin orang tua
4. Surat keterangan sehat dokter (tidak memiliki penyakit dalam & pernah mengalami
kecelakaan/operasi besar)
* :coret yang tidak perlu