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FORMULIR BIO DATA CALON MAHASISWA BARU

PROGRAM STUDI TEKNIK MESIN FT UNPAS
TAHUN AKADEMIK 2022/2023

DATA CALON MAHASISWA

NIK Calon Mahasiswa : .......................................................................................................................................

Foto
Nama Lengkap : .......................................................................................................................................
2x3

Tempat/Tanggal Lahir : .......................................................................................................................................

Alamat Asal Lengkap : .......................................................................................................................................
Kota/Kab.*) : …………………………………………………………………………… Kode Pos : ..................
Provinsi : ………………………………………………………………………………… Email : ..........................
Jenis Kelamin *) : Pria Wanita
Agama *) : Islam Katolik Protestan Budha Hindu Lainnya
Kewarganegaraan : WNI WNA
Negara Asal WNA : ................................................................. No. Pasport : .................................................
Alamat di Bandung : .......................................................................................................................................
Telepon : Rumah : ............................................................ No. Hp : ................................................
Email : .............................................................................................

DATA SEKOLAH ASAL

Nama SLTA : ......................................................................................................................................
Alamat Sekolah SLTA : ......................................................................................................................................
Kota/Kab. *) : ...................................................... Provinsi : .............................................
Pog. Studi di SLTA : IPA IPS SMK MA Paket C SMA/SMK Luar Negeri
Negara Asal Sekolah SLTA : .......................................................................................................................................
Nomor Ijazah : ....................................................................... Tahun Lulus SLTA : ...................................
Pindahan/Lanjutan dari : .......................................................................................................................................
(untuk Kelas Karyawan)*

DATA ORANG TUA

NIK Ayah/Ibu : ........................................................................./.................................................................
Nama Ayah/Ibu : ........................................................................./.................................................................
Alamat Orangtua : .......................................................................................................................................
No. HP aktif Ayah/Ibu : ......................................................................../..................................................................
Email Ayah/Ibu : ......................................................................../..................................................................
Pekerjaan Ayah/Ibu : ......................................................................../..................................................................

..................., .............................
Mengetahui: Tanda Tangan & Nama Jelas
Orang Tua,

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