SRPNM ( Sedulur Reyog Politeknik Negeri Madiun)

POLITEKNIK NEGERI MADIUN

Jl. Serayu No. 84 Madiun
Telp. ( 0351 ) 452970 Fax. (0351) 492960
Website: pnm.ac.id

FORMULIR DATA MAHASISWA BARU

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

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

Alamat Asal : ..................................................................................................................

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

Alamat Domisili (Kos) : ..................................................................................................................

Nomor Telepon : ..................................................................................................................

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

Jurusan : ..................................................................................................................

NPM : ..................................................................................................................

Jalur Masuk : ..................................................................................................................

Asal Sekolah : ..................................................................................................................

Pengalaman di bidang reyog : ..................................................................................................................

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

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

Madiun, ..................................2019

( )