UNIT KEGIATAN MAHASISWA

MAHASISWA PENCINTA ALAM SATRIA

UNIVERSITAS MUHAMMADIYAH PURWOKERTO
Sekretariat: Gd PKM Lt I UMP, Jl. Raya Dukuhwaluh 53182 Po.Box 202
Telp.(0281) 630463 ext.138 Fax.(0281) 637239
E-mail : mapalasatriaump@gmail.com Web:www.mapsa.ump.ac.id

FORMULIR PENDAFTARAN CALON ANGGOTA

MAPALA SATRIA
2014/ 2015

Nama Lengkap :
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Nama Panggilan :
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Jenis Kelamin :
Laki – Laki/ Perempuan
Tempat, Tgl Lahir :
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Golongan Darah :
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Agama :
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Fak/ Program Studi :
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Telp./HP :
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Nomer PIN BB :
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Alamat Kost :
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...................Kode Pos.......................Telp/Hp..........................
Riwayat Pendidikan : SD ....................................................Lulus Tahun..................
SLTP ................................................Lulus Tahun..................
SLTA/ SMK.....................................Lulus Tahun...................
Hoby : 1. ................................
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Pengalaman Organisasi: 1. ................................................
2. ................................................
3. ................................................
Penyakit Yang Pernah Diderita : 1. ..........................................
2. ...........................................
Motto Hidup : ......................................................
Nama Orang Tua / Wali : Ayah................................. Pekerjaan.......................
Ibu..................................... Pekerjaan.......................
Alamat Orang Tua/ Wali : ..................................................................................
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Nomer PIN BB : ........................................

Purwokerto, ................................2014
Peserta
Pas Foto
3x4
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