FORMULIR PENDAFTARAN BEASISWA

SDC SCHOLAR

BAGI ANAK PETANI

Diisi oleh MAHASISWA

SYSTEM DYNAMICS CENTER yang mengajukan
Hotline : +62 8 1111 44 234

A. DATA SISWA

PT. TRIWALA MITRA BESTARI

Po. Box 438 Bogor 16004-Indonesia
www.sysdyn.org
Office : Jl. Raya CIFOR-IPB, Komplek Griya Melati 1, Blok B1, No. 8. Bubulak-Bogor 16115
Phone :+62 251-9259266; Hotline : +62 8 1111 44 234
E-mail : triwala@gmail.com
 1. Nama Lengkap : _____________________________________________________________
2. Tempat/Tanggal Lahir : _____________________________________________________________
3. Jenis Kelamin : _____________________________________________________________
4. Alamat : _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
5. Pendidikan Formal :
a. SD/Sederajat : _____________________________________________________________
b. SMP/Sederajat : _____________________________________________________________
c. SMA/Sederajat : _____________________________________________________________
6. Prestasi
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
c. _______________________________________________________________________________________
d. _______________________________________________________________________________________
e. _______________________________________________________________________________________
7. Pengalaman Organisasi
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
c. _______________________________________________________________________________________
d. _______________________________________________________________________________________
e. _______________________________________________________________________________________
8. Kemampuan Komputer (sebutkan kemampuan penggunaan tools)
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
c. _______________________________________________________________________________________
d. _______________________________________________________________________________________
e. _______________________________________________________________________________________
9. Alamat Email : __________________________________________________________________________
10. No yang dapat dihubungi : ____________________________________________________________
Pas Foto
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Murid
Diisi oleh ORANG TUA
MAHASISWA yang
mengajukan
Keterangan :
B.  Murid
DATA tidak sedang dapat bantuan beasiswa dari pihak lain, apabila sedang menerima maka akan
KELUARGA
digugurkan dalam mendapatkan beasiswa ini
1.  Data
MohonKeluarga :
diperhatikan, bahwa keterangan yang kurang lengkap dapat menggugurkan permohonan

PT. TRIWALA MITRA BESTARI

Po. Box 438 Bogor 16004-Indonesia
www.sysdyn.org
Office : Jl. Raya CIFOR-IPB, Komplek Griya Melati 1, Blok B1, No. 8. Bubulak-Bogor 16115
Phone :+62 251-9259266; Hotline : +62 8 1111 44 234
E-mail : triwala@gmail.com
 Keluarga Nama Umur Pekerjaan
Ayah
Ibu
Kakak/Adik 1.
2.
3.
4.
5.
6.
7.

2. Luas Lahan Sawah : ___________________________m2 atau ha (coret salah satu)

3. Status Lahan Sawah : Milik sendiri/Garapan (coret salah satu)
4. Rata-rata pendapatan orang tua/bulan : Rp.________________________________________
5. Pekerjaan sampingan orang tua : ____________________________________________________
6. Selama ini biaya sekolah diperoleh dari
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7. Kendala dalam bertani
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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Orang tua Mahasiswa

Keterangan :
1. Melampirkan fotocopy transkip nilai
2. Melampirkan KTP dan KK Orang tua mahasiswa Diisi oleh DPA yang
3. Lampirkan sertifikat prestasi (jika ada) merekomendasikan

C. INFORMASI UNIVERSITAS

PT. TRIWALA MITRA BESTARI

Po. Box 438 Bogor 16004-Indonesia
www.sysdyn.org
Office : Jl. Raya CIFOR-IPB, Komplek Griya Melati 1, Blok B1, No. 8. Bubulak-Bogor 16115
Phone :+62 251-9259266; Hotline : +62 8 1111 44 234
E-mail : triwala@gmail.com
 1. Nama Universitas : _____________________________________________________________
2. Alamat : _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
3. Nama Rektor : _____________________________________________________________
4. No Telp : _____________________________________________________________
5. E-mail : _____________________________________________________________
6. Website : _____________________________________________________________

D. DATA DPA YANG MEMBERIKAN REKOMENDASI

1. Nama : _____________________________________________________________
2. Alamat : _____________________________________________________________
3. Status Dosen : _____________________________________________________________
4. NIP : _____________________________________________________________
5. No. Handphone : _____________________________________________________________
6. E-mail : _____________________________________________________________
7. Nama Mahasiswa yang direkomendasikan : ________________________________________

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DPA yang Merekomendasikan

Diisi oleh DPA yang

merekomendasikan

Pertimbangan Mengapa Calon ini Dinominasi untuk

Mendapatkan Beasiswa

Dijelaskan deskripsi calon yang diusulkan dan alasan kenapa diusulkan

PT. TRIWALA MITRA BESTARI

Po. Box 438 Bogor 16004-Indonesia
www.sysdyn.org
Office : Jl. Raya CIFOR-IPB, Komplek Griya Melati 1, Blok B1, No. 8. Bubulak-Bogor 16115
Phone :+62 251-9259266; Hotline : +62 8 1111 44 234
E-mail : triwala@gmail.com
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PT. TRIWALA MITRA BESTARI

Po. Box 438 Bogor 16004-Indonesia
www.sysdyn.org
Office : Jl. Raya CIFOR-IPB, Komplek Griya Melati 1, Blok B1, No. 8. Bubulak-Bogor 16115
Phone :+62 251-9259266; Hotline : +62 8 1111 44 234
E-mail : triwala@gmail.com