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FORMULIR REGISTRASI ULANG MAHASISWA

UNIVERSITAS SARI MULIA
BANJARMASIN

NAMA : ..............................................................................................
NIM : ..............................................................................................
FAKULTAS : ..............................................................................................
PROGRAM STUDI : ..............................................................................................
SEMESTER : ..............................................................................................
TEMPAT/TANGGAL LAHIR : ..............................................................................................
AGAMA : ..............................................................................................
SUKU : ..............................................................................................
ALAMAT ASAL : ..............................................................................................
NO : ......... RT : ......... RW : .........
KELURAHAN : .............................................................
KECAMATAN : .............................................................
KAB / KOTA : .............................................................
PROVINSI : .............................................................
NO TELP/HP : ..............................................................................................
ALAMAT SEKARANG : ..............................................................................................
NO : ......... RT : ......... RW : .........
KELURAHAN : .............................................................
KECAMATAN : .............................................................
KAB / KOTA : .............................................................
PROVINSI : .............................................................
EMAIL : ..............................................................................................

ORANG TUA
NAMA AYAH : ..............................................................................................
PEKERJAAN : ..............................................................................................
NO TELP/HP AYAH : ..............................................................................................
ALAMAT AYAH : ..............................................................................................
NO : ......... RT : ......... RW : .........
KELURAHAN : .............................................................
KECAMATAN : .............................................................
KAB / KOTA : .............................................................
PROVINSI : .............................................................

NAMA IBU : ..............................................................................................

PEKERJAAN : ..............................................................................................
NO TELP/HP IBU : ..............................................................................................
ALAMAT IBU : ..............................................................................................
NO : ......... RT : ......... RW : .........
KELURAHAN : .............................................................
KECAMATAN : .............................................................
KAB / KOTA : .............................................................
PROVINSI : .............................................................
WALI YANG BISA DIHUBUNGI
NAMA WALI : ..............................................................................................
HUBUNGAN DGN MAHASIWA : ..............................................................................................
JENIS KELAMIN : ..............................................................................................
PEKERJAAN : ..............................................................................................
NO TELP/HP WALI : ..............................................................................................
ALAMAT WALI : ..............................................................................................
NO : ......... RT : ......... RW : .........
KELURAHAN : .............................................................
KECAMATAN : .............................................................
KAB / KOTA : .............................................................
PROVINSI : .............................................................

DEMIKIAN FORMULIR INI DI ISI DENGAN SEBENAR-BENARNYA

BANJARMASIN, ...........................20...

(............................................................)

Lembar Diisi oleh Petugas

Cek Kelengkapan Berkas :

Bukti Kuitansi Pembayaran Trimester (SPP Terakhir) dan SKS (Fotocopy)

Kartu Tanda Mahasiswa (Fotocopy)

Bukti Pembayaran Registrasi Semester (Asli)

KHS (Asli)

KRS (Asli)

Bukti Bebas Pustaka (Asli)

Bukti Bebas Peminjaman Alat Laboratorium Kesehatan (Asli)

Tanda Pengenal / ID Card (Fotocopy)

Bebas Laporan Pre Ners (Bagi Mahasiswa Prodi Ners)

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