FORMULIR PENDAFTARAN

HIMPUNAN MAHASISWA
KEPERAWATAN PURWOKERTO
POLTEKKES KEMENKES SEMARANG
MASA BAKTI 2020
Jl. Adipati Mersi Purwokerto Kotak Pos 122 Telepon (0281) 637356 Purwokerto
53101

INFORMASI PRIBADI

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

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

TTL :............................................................................

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

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

Golongan Darah :............................................................................

Nomor WA :............................................................................
4x6
Alamat Rumah :............................................................................

Hobby :............................................................................

Alamat Kos :............................................................................ KEMAMPUAN-KEAHLIAN

PENGALAMAN ORGANISASI Video Editor (Filmora,

Premiere, Corel Video, dll)
Ada Tidak Ada
Design Grafis(Photoshop,
(Jika Ada)
Corel Draw,dll)
1....................................................sebagai.......................................................
Public Speaking
2....................................................sebagai.......................................................
Bisnis
3....................................................sebagai.......................................................
Tulis-Menulis
4....................................................sebagai.......................................................
Talent (Music, Dance
5....................................................sebagai.......................................................
dll)

Tartil,Qiro’ah, dll

Lainnya

PRESTASI YANG PERNAH DIRAIH

(AKADEMIK/NON-AKADEMIK) MOTTO HIDUP
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 SEBAGAI
(Centang yang dipilih)

WAKIL GUBERNUR HIMA SEKRETARIS HIMA BENDAHARA HIMA

DIVISI PENELITIAN DAN PENGEMBANGAN (LITBANG)

DIVISI MINAT DAN BAKAT (MIBA) DIVISI ROHANI ISLAM (ROHIS)

DIVISI SOSIAL DIVISI KKM DIVISI WIRAUSAHA (WIRUS)

PROGRAM KERJA BARU DAN HAL YANG INGIN ANDA KERJAKAN SEBAGAI HIMA

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 Demikian formulir pendaftaran ini saya isi dengan sebenar-benarnya ada dengan penuh
rasa tanggung jawab dan dengan ini
Dengan ini Saya mendaftarkan diri untuk menjadi bagian dari Keluarga Besar Himpunan
Mahasiswa Keperawatan Purwokerto Poltekkes Kemenkes Semarang.

Purwokerto, 2019

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