PANITIA PELAKSANA PEMILIHAN

HMJ SEMA DAN DEMA

FAKULTAS SAINS DAN TEKNOLOGI
UNIVERSITAS ISLAM NEGERI SUMATERA UTARA
Alamat : Jl. IAIN No.1 Medan 20235
Telp. 082277446277 E-Mail: kpusaintek@gmail.com

FORMULIR PENDAFTARAN

CALON KETUA HIMPUNAN MAHASISWA JURUSAN PERIODE 2019-2020

I. BIODATA DIRI

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

Nama Panggilan : .............................................................................................................

Jenis Kelamin : .............................................................................................................

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

NIM : .............................................................................................................

Fakultas/Jurusan : .............................................................................................................

Agama : .............................................................................................................

No HP/Telp : .............................................................................................................

Email : .............................................................................................................

Facebook/Twitter : .............................................................................................................

Blog/Website : .............................................................................................................

Anak Ke-.., dari-.., Bersaudara : .............................................................................................................

Asal Daerah : .............................................................................................................

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

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

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

Motivasi jadi Ketua HMJ : .............................................................................................................

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

.............................................................................................................
 PANITIA PELAKSANA PEMILIHAN
HMJ SEMA DAN DEMA
FAKULTAS SAINS DAN TEKNOLOGI
UNIVERSITAS ISLAM NEGERI SUMATERA UTARA
Alamat : Jl. IAIN No.1 Medan 20235
Telp. 082277446277 E-Mail: kpusaintek@gmail.com

II. DAFTAR RIWAYAT HIDUP

1. Prestasi Akademik dan non Akademik

No Prestasi Tingkat Tahun

1
2
3
4
5

2. Pengalaman Organisasi

No Organisasi Tingkat Tahun

1
2
3
4
5

3. Riwayat Pendidikan

No Pendidikan Formal Tempat Tahun

1 TK
2 SD/MI
3 SMP/MTS
4 SMA/MA
5 PT

Demikian formulir pendaftaran ini saya isi dengan sebenarnya. Jika suatu saat nanti terdapat
kekeliruan di dalamnya maka saya siap menerima sanksi sesuai dengan ketentuan yang berlaku.

Medan, ..... Oktober 2019

Calon Ketua HMJ .................

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

FORMULIR PENDAFTARAN
 PANITIA PELAKSANA PEMILIHAN
HMJ SEMA DAN DEMA
FAKULTAS SAINS DAN TEKNOLOGI
UNIVERSITAS ISLAM NEGERI SUMATERA UTARA
Alamat : Jl. IAIN No.1 Medan 20235
Telp. 082277446277 E-Mail: kpusaintek@gmail.com

CALON KETUA DEWAN MAHASISWA FAKULTAS PERIODE 2019-2020

I. BIODATA DIRI

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

Nama Panggilan : .............................................................................................................

Jenis Kelamin : .............................................................................................................

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

NIM : .............................................................................................................

Fakultas/Jurusan : .............................................................................................................

Agama : .............................................................................................................

No HP/Telp : .............................................................................................................

Email : .............................................................................................................

Facebook/Twitter : .............................................................................................................

Blog/Website : .............................................................................................................

Anak Ke-.., dari-.., Bersaudara : .............................................................................................................

Asal Daerah : .............................................................................................................

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

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

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

Motivasi jadi Ketua DEMA-F : .............................................................................................................

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

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

II. DAFTAR RIWAYAT HIDUP

 PANITIA PELAKSANA PEMILIHAN
HMJ SEMA DAN DEMA
FAKULTAS SAINS DAN TEKNOLOGI
UNIVERSITAS ISLAM NEGERI SUMATERA UTARA
Alamat : Jl. IAIN No.1 Medan 20235
Telp. 082277446277 E-Mail: kpusaintek@gmail.com

1. Prestasi Akademik dan non Akademik

No Prestasi Tingkat Tahun

1
2
3
4
5

2. Pengalaman Organisasi

No Organisasi Tingkat Tahun

1
2
3
4
5

3. Riwayat Pendidikan

No Pendidikan Formal Tempat Tahun

1 TK
2 SD/MI
3 SMP/MTS
4 SMA/MA
5 PT

Demikian formulir pendaftaran ini saya isi dengan sebenarnya. Jika suatu saat nanti terdapat
kekeliruan di dalamnya maka saya siap menerima sanksi sesuai dengan ketentuan yang berlaku.

Medan, ..... Oktober 2019

Calon Ketua DEMA-F

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

FORMULIR PENDAFTARAN

CALON KETUA SENAT MAHASISWA FAKULTAS PERIODE 2019-2020

 PANITIA PELAKSANA PEMILIHAN
HMJ SEMA DAN DEMA
FAKULTAS SAINS DAN TEKNOLOGI
UNIVERSITAS ISLAM NEGERI SUMATERA UTARA
Alamat : Jl. IAIN No.1 Medan 20235
Telp. 082277446277 E-Mail: kpusaintek@gmail.com

I. BIODATA DIRI

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

Nama Panggilan : .............................................................................................................

Jenis Kelamin : .............................................................................................................

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

NIM : .............................................................................................................

Fakultas/Jurusan : .............................................................................................................

Agama : .............................................................................................................

No HP/Telp : .............................................................................................................

Email : .............................................................................................................

Facebook/Twitter : .............................................................................................................

Blog/Website : .............................................................................................................

Anak Ke-.., dari-.., Bersaudara : .............................................................................................................

Asal Daerah : .............................................................................................................

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

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

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

Motivasi jadi Ketua SEMA-F : .............................................................................................................

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

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

II. DAFTAR RIWAYAT HIDUP

1. Prestasi Akademik dan non Akademik

 PANITIA PELAKSANA PEMILIHAN
HMJ SEMA DAN DEMA
FAKULTAS SAINS DAN TEKNOLOGI
UNIVERSITAS ISLAM NEGERI SUMATERA UTARA
Alamat : Jl. IAIN No.1 Medan 20235
Telp. 082277446277 E-Mail: kpusaintek@gmail.com

No Prestasi Tingkat Tahun

1
2
3
4
5

2. Pengalaman Organisasi

No Organisasi Tingkat Tahun

1
2
3
4
5

3. Riwayat Pendidikan

No Pendidikan Formal Tempat Tahun

1 TK
2 SD/MI
3 SMP/MTS
4 SMA/MA
5 PT

Demikian formulir pendaftaran ini saya isi dengan sebenarnya. Jika suatu saat nanti terdapat
kekeliruan di dalamnya maka saya siap menerima sanksi sesuai dengan ketentuan yang berlaku.

Medan, ..... Oktober 2019

Calon Ketua SEMA-F

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