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FORMULIR PENDAFTARAN

CALON PENGURUS HMJ GIZI TAHUN 2022


POLTEKKES KEMENKES BENGKULU

A. INDENTITAS DIRI
Nama : PAS FOTO
Nim/Prodi :
FORMAL
No.Hp :
Alamat E-mail : (3X4)
Sosial Media :

B. RIWAYAT HIDUP
Nama Lengkap :
Nama panggilan :
Agama :
Jenis kelamin :
Tempat/Tanggal Lahir :
Alamat Tempat Tinggal :
Alamat Asal :
Hobi :

ORANG TUA
Nama Ayah :
Pekerjaan Ayah :
Nama Ibu :
Pekerjaan Ibu :

C. RIWAYAT PENDIDIKAN

No Nama Sekolah Tahun Masuk Tahun Lulus


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1.
2.
3.

D. PRESTASI ORGANISASI AKADEMIK/NON AKADEMIK (JIKA ADA LAMPIRKAN)

No Bidang Prestasi Tahun Tingkat


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1.
2.
3.
*) Prestasi yang diraih dalam 3 tahun terakhir
E. ALASAN INGIN MASUK HMJ GIZI

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MINAT MASUK KE DIVISI

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ALASAN MEMILIH DIVISI TERSEBUT

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Bengkulu, 2021

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