HIMPUNAN MAHASISWA JURUSAN AKUNTANSI

POLITEKNIK NEGERI SAMARINDA

Jalan Dr. Cipto Mangunkusumo Kampus Gunung Lipan PO BOX 1341
 (0541) 260588 – 262018 Samarinda 75131
FORMULIR PENDAFTARAN
CALON PENGURUS
HIMPUNAN MAHASISWA JURUSAN AKUNTANSI
PERIODE 2020/2021

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

2. Nama Panggil : ....................................................................... FOTO
3. Tempat, Tanggal Lahir : .......................................................................
3X4
4. Jenis Kelamin : .......................................................................
5. Alamat Asal : .......................................................................
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6. Alamat Sekarang : .......................................................................
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7. NIM & IPK : .......................................................................
8. Kelas/Prodi : .......................................................................
9. Asal Sekolah : .......................................................................
10. Sosmed
WA : .....................................................................................................
IG : .....................................................................................................
11. Pengalaman Organisasi
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12. Kategori pilihan Bidang :
o Keorganisasian (.....)
o Pendidikan dan Kemahasiswaan (.....)
o Minat dan Bakat (.....)
o Dana dan Usaha (.....)
o Kerohanian (.....)
Catatan : Beri nomor sesuai Prioritas Anda

13. Alasan Masuk HMJ :

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14. Syarat – syarat dilampirkan :
1) Fotocopy KTM 2 Lembar
2) Foto 3x4 3 (tiga) Lembar

Dengan ini saya menyatakan bahwa saya bermaksud sungguh-sungguh mendaftarkan diri
sebagai pengurus Himpunan Mahasiswa Jurusan Akuntansi Periode 2020/2021. Saya juga
bersedia memenuhi peraturan dalam kepengurusan ini, formulir ini saya isi dengan sebenar-
benarnya.
Samarinda,..................................... 2020

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