POLITEKNIK NEGERI SRIWIJAYA

KOMISI PEMILIHAN UMUM

Jalan Srijaya Negara Bukit Besar Palembang 30139
Telepon (0711) 353414, Faksimil (0711) 35591
Website:www.kpu.polsri.ac.id, E-mail:kpu@polsri.ac.id, CP: 081278626966

FORMULIR PENDAFTARAN CALON ANGGOTA MPM

PEMILU KM-POLSRI 2019/2020

Nama : ..................................................................................
Tempat/Tanggal Lahir : ………………………...........................................................
Alamat : ..................................................................................
............................... Telp./Hp .....................................
Jurusan : ..................................................................................
Pengalaman Organisasi
Intra Kampus
1. Tahun .......... Sebagai ......................
2. Tahun .......... Sebagai ......................
3. Tahun .......... Sebagai ......................

Ekstra Kampus/Sekolah
1. Tahun .......... Sebagai ......................
2. Tahun .......... Sebagai ......................
3. Tahun .......... Sebagai ......................

Demikianlah formulir ini saya isi dengan sebenar-benarnya untuk dapat

dipertanggung jawabkan.

Palembang, 2019

Photo 4x6
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 POLITEKNIK NEGERI SRIWIJAYA
KOMISI PEMILIHAN UMUM
Jalan Srijaya Negara Bukit Besar Palembang 30139
Telepon (0711) 353414, Faksimil (0711) 35591
Website:www.kpu.polsri.ac.id, E-mail:kpu@polsri.ac.id, CP: 081278626966

CURRICULUM VITAE

Nama : ..................................................................................
Jenis Kelamin : Laki-laki/Perempuan
Agama : ..................................................................................
Alamat : ..................................................................................
............................... Telp./Hp .....................................
Riwayat Pendidikan Formal
1. SD .................................... di.........................Tamat Tahun......................
2. SMP .................................. di.........................Tamat Tahun......................
3. SMA .................................. di.........................Tamat Tahun......................

Riwayat Pendidikan Non Formal

1. di .................................... Tamat Tahun ...........
2. di .................................... Tamat Tahun ...........
3. di .................................... Tamat Tahun ...........

Prestasi Yang Pernah Diraih

1. di .................................... Tahun ....................
2. di .................................... Tahun ....................
3. di .................................... Tahun ....................

Orang Tua
Nama Ayah / Ibu : ..................................... / ................................
Tanggal Lahir : ..................................... /.................................
Pendidikan Terakhir : ..................................... /.................................
Alamat : ........................................................................
Pekerjaan : ..................................... /.................................

Pendapat dan Saran Bagi Keluarga Mahasiswa Politeknik Negeri Sriwijaya :

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 POLITEKNIK NEGERI SRIWIJAYA
KOMISI PEMILIHAN UMUM
Jalan Srijaya Negara Bukit Besar Palembang 30139
Telepon (0711) 353414, Faksimil (0711) 35591
Website:www.kpu.polsri.ac.id, E-mail:kpu@polsri.ac.id, CP: 081278626966

Visi :
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..................................................................................................................
Misi :
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Program Apa Yang Akan Anda Wujudkan Ketika Terpilih :

1. Program Jangka Panjang
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2. Program Jangka Pendek

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Kutipan Yang Menjadi Semangat Anda

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 POLITEKNIK NEGERI SRIWIJAYA
KOMISI PEMILIHAN UMUM
Jalan Srijaya Negara Bukit Besar Palembang 30139
Telepon (0711) 353414, Faksimil (0711) 35591
Website:www.kpu.polsri.ac.id, E-mail:kpu@polsri.ac.id, CP: 081278616966