SEKOLAH TINGGI KEGURUAN DAN ILMU PENDIDIKAN

PERSATUAN GURU REPUBLIK INDONESIA

(STKIP PGRI) SUKABUMI
STATUS TERAKREDITASI BAN-PT. DEPDIKNAS REPUBLIK INDONESIA
NOMOR : 021/BAN-PT/Ak-X/XII/2006 DAN NOMOR : 036/BAN-PT/Ak-XII/S1/XI/2009
Jl. Karamat No. 69 Kota Sukabumi Telp (0266) 231745
Telp. (0266) 231745 Fax: (0266) 231758 Email :stkip.pgri_sukabumi@yahoo.co.id

FORMULIR PENDAFTARAN MAHASISWA BARU (PMB)

TAHUN AKADEMIK 2021/2022

A. IDENTITAS CALON MAHASISWA

Nama Lengkap *) :..............................................................................................................
Tempat Lahir & Tanggal lahir *) :..............................................................................................................
Jenis Kelamin *) :..............................................................................................................
Agama *) :..............................................................................................................
Status Perkawinan :..............................................................................................................
Pekerjaan :..............................................................................................................
NIK *) :..............................................................................................................
Alamat Rumah :..............................................................................................................
Dusun/RT/RW :..............................................................................................................
Kelurahan *) :..............................................................................................................
Kecamatan *) :..............................................................................................................
Kode Pos :..............................................................................................................
Jenis Tinggal : Bersama Orang Tua Kost Lainnya :.........................
No Telepon/HP :..............................................................................................................
Email :..............................................................................................................
Penerima Keluarga Prasejahtera/: Ya Tidak No. KPS/KIP :.......................................................
Kartu Indonesia Pintar
Program Studi Pilihan*) : Pendidikan Ekonomi PPKn
Kelas*) : Reguler Non Reguler/Karyawan

B. AYAH
Nama :..............................................................................................................
Tanggal Lahir :..............................................................................................................
Pendidikan terakhir :..............................................................................................................
Pekerjaan :..............................................................................................................

C. IBU
Nama IBU *) :..............................................................................................................
Tanggal Lahir :..............................................................................................................
Pendidikan terakhir :..............................................................................................................
Pekerjaan :..............................................................................................................

D. WALI
Nama :..............................................................................................................
Tanggal Lahir :..............................................................................................................
Pendidikan :..............................................................................................................
Pekerjaan :..............................................................................................................

E. Sekolah Asal
Nama Sekolah :..............................................................................................................
Tahun Lulus :..............................................................................................................

F. KHUSUS UNTUK MAHASISWA LANJUTAN/PINDAHAN :

Nama Perguruan Tinggi Asal :..............................................................................................................
Program Studi :..............................................................................................................
Tahun Masuk :..............................................................................................................
Nomor Pokok Mahasiswa :..............................................................................................................
Semester/Tahun Keluar :..............................................................................................................
 SEKOLAH TINGGI KEGURUAN DAN ILMU PENDIDIKAN
PERSATUAN GURU REPUBLIK INDONESIA
(STKIP PGRI) SUKABUMI
STATUS TERAKREDITASI BAN-PT. DEPDIKNAS REPUBLIK INDONESIA
NOMOR : 021/BAN-PT/Ak-X/XII/2006 DAN NOMOR : 036/BAN-PT/Ak-XII/S1/XI/2009
Jl. Karamat No. 69 Kota Sukabumi Telp (0266) 231745
Telp. (0266) 231745 Fax: (0266) 231758 Email :stkip.pgri_sukabumi@yahoo.co.id

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3x4 3x4 2x3 2x3

Keterangan :
 Beri nama dibelakangnya
 Lem diatasnya saja
 *) Harus diisi
 Pilih salah Satu
Lampiran – Lampiran :
Lampiran 1 : Fotocopy/Softfile Ijazah SMA Sederajat yang sudah dilegalisasi sebanyak 2 lembar
Lampiran 2 : Fotocopy/Softfile Akta Kelahiran
Lampiran 3 : Fotocopy/Softfile Kartu Identitas KTP / SIM Calon Mahasiswa
Lampiran 4 : Fotocopy/Softfile Kartu Keluarga
Lampiran 5 : Fotocopy/Softfile Kwitansi/Bukti Pembayaran Pendaftaran yang sudah lunas

Sukabumi,……………………………………………
Calon Mahasiswa/i

Scan Kode QR diatas untuk Formulir online

Atau masuk ke link https://bit.ly/PMB-STKIP-PGRI-2021 ……………………………………………………………

Form Rekomendasi (Pemberi Usulan/Ajakan masuk ke STKIP PGRI Sukabumi)

Nama :……………………………………………………………………………………………………
Pekerjaan : ……………………………………………………………………………………………………
No Hp/Wa : ……………………………………………………………………………………………………

*Form rekomendasi ini wajib diisi apabila mendaftar ke STKIP PGRI Sukabumi atas usulan guru BK, teman, dll. K osongkan
apabila mendaftar atas inisiatif sendiri.