HIMPUNAN MAHASISWA AKUAKULTUR (HIMAKUA)

FAKULTAS PERTANIAN
UNIVERSITAS SRIWIJAYA
Sekretariat : Lt.2 Gedung Lembaga Penelitian Universitas Sriwijaya
Program Studi Budidaya Perairan
JL. Pelembang Prabumulih Km 32 Indralaya (Ogan Ilir) 30662

DATA DIRI MAHASISWA

PROGRAM STUDI BUDIDAYA PERAIRAN
FAKULTAS PERTANIAN
UNIVERSITAS SRIWIJAYA
TAHUN AJARAN 2014/2015

Nama : ..........................................................................
Program Studi : BUDIDAYA PERAIRAN
Strata Pendidikan : S1 (Strata 1)

1. DATA PRIBADI

Nama Mahasiswa : ..........................................................................

NIM : ..........................................................................
Tempat Tanggal Lahir : ..........................................................................
Jenis Kelamin : LAKI-LAKI/PEREMPUAN
Ukuran Baju : S/M/L/XL
Golongan Darah : A/B/AB/O
Penyakit penting yang pernah dialami : ..........................................................................
Agama : ..........................................................................
Anak Ke- : .................dari...................bersaudara
Kewarganegaraan : INDONESIA ASLI/KETURUNAN/WNA
Alamat Tinggal Selama Mengikuti Pendidikan : ..........................................................................
No. Telp/HP : ..........................................................................
UKT Per Semester : ..........................................................................

2. DATA PENDIDIKAN

Tingkat Nama Sekolah/PT Jurusan Lokasi Tahun Lulus

Kab/Kodya/Prov
TK
SD
SMP
SMA
3. PENGALAMAN ORGANISASI

a. Organisasi Intra Sekolah

Nama Organisasi Jabatan Tahun

b. Organisasi Ekstra Sekolah

 HIMPUNAN MAHASISWA AKUAKULTUR (HIMAKUA)
FAKULTAS PERTANIAN
UNIVERSITAS SRIWIJAYA
Sekretariat : Lt.2 Gedung Lembaga Penelitian Universitas Sriwijaya
Program Studi Budidaya Perairan
JL. Pelembang Prabumulih Km 32 Indralaya (Ogan Ilir) 30662

Nama Organisasi Jabatan Tahun

4. BAKAT/HOBI/KEGEMARAN

1. .................................................................................
2. .................................................................................
3. .................................................................................

5. PRESTASI-PRESTASI YANG PERNAH DIRAIH

1. .................................................................................
2. .................................................................................
3. .................................................................................
4. .................................................................................
5. .................................................................................

6. DATA KELUARGA

AYAH
Nama : ...........................................................................................
Pekerjaan : ...........................................................................................
Pendidikan Terakhir : ...........................................................................................
Penghasil Sebulan (Rp) : ...........................................................................................
Alamat Rumah : ...........................................................................................
No. Telp/HP : ...........................................................................................
IBU
Nama : ...........................................................................................
Pekerjaan : ...........................................................................................
Pendidikan Terakhir : ...........................................................................................
Penghasil Sebulan (Rp) : ...........................................................................................
Alamat Rumah : ...........................................................................................
No. Telp/HP : ...........................................................................................