KEMENTERIAN PENDIDIKAN, KEBUDAYAAN, RISET DAN TEKNOLOGI

POLITEKNIK NEGERI MADIUN

Jalan Serayu Nomor 84 Madiun Kode Pos 63133
Telepon +62 351 452970 Faksimile +62 351 452960
Laman : www.pnm.ac.id, Surel : sekretariat@pnm.ac.id

FORMULIR DAFTAR ULANG – SBMPN 2022

PENERIMAAN MAHASISWA BARU TAHUN AKADEMIK 2022 – 2023
BIODATA MAHASISWA
I. DATA DIRI Pas foto warna
3x4
1. NO. PENDAFTARAN SNMPTN : ...................................................................................................
2. NISN : ...................................................................................................
3. NAMA LENGKAP : ....................................................................................................
4. JENIS KELAMIN : LAKI – LAKI / PEREMPUAN (*coret yang tidak perlu)
5. AGAMA : ....................................................................................................
6. TEMPAT LAHIR : ....................................................................................................
7. TANGGAL LAHIR : .............................................................................................................................................................
8. ALAMAT (RT / RW, DESA) : .............................................................................................................................................................
9. KECAMATAN : .............................................................................................................................................................
10. KAB. / KOTA : .............................................................................................................................................................
11. PROVINSI : .............................................................................................................................................................
12. TELP. / HP : .............................................................................................................................................................
13. EMAIL : .............................................................................................................................................................
14. UKURAN ALMAMATER : S / M / L / XL / XXL / XXXL / XXXXL (*coret yang tidak perlu)
/ BAJU PRODI
II. DATA PENDIDIKAN
1. SEKOLAH ASAL : .............................................................................................................................................................
2. JURUSAN ASAL : .............................................................................................................................................................
3. TAHUN LULUS : .............................................................................................................................................................

III. DATA KELUARGA

1. NAMA AYAH : .............................................................................................................................................................
2. NAMA IBU : .............................................................................................................................................................
3. NAMA WALI : .............................................................................................................................................................
4. PEKERJAAN AYAH : .............................................................................................................................................................
5. PEKERJAAN IBU : .............................................................................................................................................................
6. PEKERJAAN WALI : .............................................................................................................................................................
7. PENDAPATAN AYAH PER BULAN : .............................................................................................................................................................
8. PENDAPATAN IBU PER BULAN : .............................................................................................................................................................
9. PENDAPATAN WALI PER BULAN : .............................................................................................................................................................
10. JMLH. TANGGUNGAN ANAK : .............................................................................................................................................................
11. NO. HP ORANG TUA / WALI : .............................................................................................................................................................
IV. PENGESAHAN
Demikian formulir biodata ini saya buat dengan sebenar-benarnya dan tanpa paksaan dari pihak manapun. Apabila dikemudian hari terbukti
bahwa saya memberikan keterangan yang tidak benar, maka saya bersedia menerima segala sanksi sesuai dengan perundang- undangan yang
berlaku.
Madiun,
ORANG TUA/WALI CALON MAHASISWA CALON MAHASISWA

Materai 10 ribu
…………………………………………………… …………………………………………….
nama terang dan tanda tangan nama terang dan tanda tangan