FAKULTAS TEKNOLOGI INDUSTRI KODE: ADMI.

01
T. Elektro - T. Kimia - T. Mesin
UNIVERSITAS JAYABAYA
Email: info@ftijayabaya.ac.id Homepage:www.ftijayabaya.ac.id
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FORMULIR PENDAFTARAN
PROGRAM................. ANGKATAN......... TAHUN AKADEMIK 20....... / 20

Nomor Seleksi (Diisi oleh Petugas) FTI....................................

Keterangan :
 *) Beri tanda silang (X) pada Titik- titik jawaban yang sesuai. 
Diisi dengan huruf cetak/balok selengkap-lengkapnya

A. JURUSAN DAN KONSENTRASI YANG DIPILIH :

1. J u r u s a n *) :........... Teknik Elektro (S1 TE) ...... Teknik Mesin (S1 TM) ...... Teknik Kimia (S1 TK)
2. Kode dan Nama Konsentrasi (kosongkan untuk kelas karyawan malam) : :
.......... :..........................................................................................................................................
B. BIODATA MAHASISWA :
B.1 Personal
1. N a m a ..........................................................................................................................................................
2. Jenis Kelamin *) ..... Laki-Laki ..... Perempuan
3. Tempat/Tanggal Lahir....................................................................................... /........... /....... /...............
4. Kewarganegaraan *)........... WNI............... WNA................ WNI Keturunan
5. No. Induk KTP ................................................................................................................................................
6. A g a m a *) ..... Islam ..... Katolik ..... Protestan ..... Hindu ..... Budha
7. Status Perdata *) ..... Belum Menikah ..... Menikah ..... Janda ..... Duda
8. Alamat Rumah .........................................................................................................................................................

RT/RW.............. /........ No.......... Kelurahan.......................................................................................................

Kecamatan.....................................................................................................................................................................
K o t a...................................................................................... Kode Pos............................. (Diisi dengan lengkap)
Status Tem. Tinggal *) :
..... Rumah Sendiri/Keluarga ..... Sewa ..... Asrama
No. Telp.................... -............................................. (Kode Wilayah - Nomor), (Wajib Diisi)
No. HP......................................................................................

E-Mail..............................................................................
9. Alamat Tempat tinggal yang mudah di hubungi : ( JABODETABEK )
...................................................................................................................................................................................
10 . Sekolah/ Perguruan Tinggi Asal.............. SMK....... SMU....... UNIVERSITAS....... POLTEK...... AKADEMI...........

Nama Sekolah/ PT ...................................................................................................................................................

S t a t u s *) ..... Negeri........ Swasta Th. Masuk................... Th. Lulus.........................
No. Induk ....................................................................................................................................................................
Jurusan/Program Studi.................................................................................................................................................
Konsentrasi ................................................................................................................................................................
11. Pekerjaan *) .... Belum Bekerja ..... Sudah Bekerja
 B.2. Perusahaan/Instansi : (Khusus Yang Telah Bekerja)
Nama Perusahaan................................................................................................................................................................
Bidang .............................................................................................................................................................................
Jabatan .............................................................................................................................................................................
Alamat Lengkap ................................................................................................................................................................

No. Telepon ................ -...........................

C. DATA ORANG TUA/WALI CALON MAHASISWA :
1. Bapak ..............................................................................................................................................................
2. Ibu Kandung ....................................................................................................................................................
3. Pekerjaan ........................................................................................................................................................
4. Alamat Orang Tua/Wali......................................................................................................................................
RT/RW................. /................ Kelurahan..................................................................................................
Kecamatan........................................................................................................................................................
K o t a....................................................................................... Kode Pos............................... (Wajib Diisi)
No. Telp................... -......................................... (Kode Wilayah - Nomor)

Jakarta,............................................20..........
Calon Mahasiswa,

Foto
3x4

Note : Foto ditempel ! (.................................................... )

Direkomendasikan Oleh : ( mohon diisi lengkap ! ) *)

Nama :............................................... Nama BANK :.........................................

NPM :............................................... Nama Rekening :.........................................
NIK :............................................... No. Rekening :.........................................
No. HP :............................................... Kantor Cabang (non BCA) :..........................................
Alamat :...............................................

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*) Syarat dan ketentuan berlaku.