FORMULIR PENDAFTARAN HIMPUNAN

MAHASISWA JURUSAN KEPERAWATAN

UNIVERSITAS BENGKULU
MASA KHIDMAT 2020-2021
Alamat : Jl. Indragiri No. 4 Padang Harapan(38225)

FORMULIR PENDAFTARAN HIMA KEP 2021

informasi pribadi

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

Nim : ............................................................................

Tempat Lahir : ............................................................................

Agama : ............................................................................ 3X4

Tanggal Lahir : ............................................................................

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

No. Telp/Hp : ............................................................................

Alamat Rumah : ............................................................................

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

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

Pengalaman organisasi Public Speaking

Design Grafis (Photo Shop,

Ada Tidak Ada
Corell Draw, dll)
(Jika Ada)
Iptek
1....................................................sebagai.......................................................
Tulis-Menulis
2....................................................sebagai.......................................................
Talent (Music, Dance)
3....................................................sebagai.......................................................
Banjari, Qiro’ah
4....................................................sebagai.......................................................
Lainnya
5....................................................sebagai.......................................................

Prestasi yang pernah diraih (akedemik-non akademik

Motto hidup

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 Yang anda ketahui tentang himpunan mahasiswa jurusan Keperawatan

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Alasan anda ingin bergabung di himpunan mahasiswa jurusan Keperawatan

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Bidang Yang Di Ajukan

Silakan di ajukan 2 Pilihan menggunakan minat dan bakat :

1. SEKRETARIS

2. BENDAHARA

3. CO PENDIDIKAN

4. CO HUMAS

5. CO SENI DAN OLAHRAGA

6. CO BISTEK DAN TEKNOLOGI

7. CO KEROHANIAN

8. CO KOMINFO
BIDANG PENDIDIKAN
BIDANG KEROHANIAN
BIDANG BISTEK DAN TEKNOLOGI
BIDANG SENI DAN OLAHRAGA
BIDAGN HUMAS
BIDANG KOMINFO

Demikian formulir pendaftaran ini saya isi dengan sebenar-benarnya dan dengan penuh rasa tanggung
jawab. Dengan ini saya mendaftarkan diri untuk menjadi bagian dari keluarga besar
HIMA KEP Masa Khidmat 2021-2022

Bengkulu, 2020
Yang betanda tangan Bupati HIMA KEP

(............................................) ( Efrizal Novsawindi )