AKADEMI KEBIDANAN

WIRA HUSADA NUSANTARA MALANG

Jl. Kecubung No. 2, Tlogomas Malang-65144
Telepon : 0341-558873, 773890 Fax : 0341-558873
Email : info@akbidwhn.com / akbidwhnmlg@gmail.com
D3 Bidan : DepKes : HK.03.2.41.04153 DIKTI : 13758/D/T/K-VII/2012
Terakreditasi B LAM-PTKes No. 0045/LAM-PTKes/Akr/Dip/I/2017

FORMULIR PENDAFTARAN

DATA CALON MAHASISWA

Nama : ........................................................................................................
Tempat/Tanggal lahir : ................................................................. Gol. Darah : .................
Agama : .................................................. Status : Menikah/Belum menikah
Alamat Asal : ........................................................................................................
Kelurahan : ............................... Kecamatan : ...............................
Kota/Kabupaten : .............................................................................
No.Telp/Hp : .................................................. Email : ...............................
Alamat di Malang : ........................................................................................................
Kelurahan : ............................... Kecamatan : ...............................
Kota/Kabupaten : .............................................................................
No Telp/Hp : ........................................................................................................
Pendidikan Tertinggi : a. SMA/SMK b. SPK c. D1/P2B d. .....................................
Asal sekolah : ........................................................................................................
Jurusan : ................................................. Kota/Kabupaten : ........................
Tahun Lulus : ................................................. Bekerja : Ya/Tidak
Alamat Sekolah : ........................................................................................................

ADMINISTRASI
NRM : ................................................. Keterangan : ...............................

DATA ORANG TUA

Nama Ayah : ................................................. Nama Ibu : ..................................
Pekerjaan Ayah :.................................................. Pekerjaan Ibu :.............................
Alamat : ........................................................................................................
Kelurahan : .............................. Kecamatan : ...............................
Kota/Kabupaten : .............................................................................
No. Telp. Rumah : ................................................. No HP : ......................................
Penanggung jawab Keuangan : ........................................................................................................
Nama : ........................................................................................................
Hubungan dengan calon mahasiswa: Ayah/Ibu/Lain-lain, sebutkan...........................................
Alamat : ........................................................................................................
Kelurahan : .............................. Kecamatan : ................................
Kota/Kabupaten : .............................................................................
No. Telp. Rumah : ................................................. No Hp : .......................................

Anda memperoleh informasi tentang program studi kebidanan dari :

a. Informasi dari teman/saudara
b. Iklan media massa : a. Koran b. Radio c. Acara TV
c. Brosur
d. Lain-lain, sebutkan : ....................................................................................................................

Malang,
Panitia Pendaftaran Pendaftar

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