Nama :.......................................................................
Alamat :..........................................................................
...........................................................................
No. HP :.........................................................................
Pekerjaan :.......................................................................
Adalah orang tua /wali dari mahasiswa baru Fakultas Teknik UGM ssb :
Nama :.....................................................................
Alamat :...................................................................
....................................................................
No. HP :...................................................................
Dengan ini menyatakan / menjelaskan mengenai detail dari pekerjaan /usaha/wiraswasta yang saya
miliki :
1. Nama Pekerjaan /
Usaha/wiraswasta ................................................................................
Bidang
2. Modal
2. ....................................................................................................
3. ....................................................................................................
4. ....................................................................................................
5. .....................................................................................................
5 Jumlah pegawai ........................................................................................................
..........................................................................................................
6 Rata – rata
penghasilanper bulan ........................................................................................................
........................................................................................................
7 Lain- lain (uraikan
tentang usaha ...........................................................................................................
/pekerjaan tersebut
...........................................................................................................
...........................................................................................................
............................................................................................................
.............................................................................................................
............................................................................................................
............................................................................................................
.............................................................................................................
............................................................................................................
Yogyakarta , ................................................
Yang menyatakan
......................................................................