KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN,

RISET, DAN TEKNOLOGI

POLITEKNIK NEGERI PONTIANAK
Jalan Jenderal Ahmad Yani - Pontianak 78124, Kalimantan Barat
Telepon: (0561)736180, Faksimile: (0561) 740143, Kotak Pos 1286
Laman: www.polnep.ac.id

Biodata Mahasiswa Baru

Tahun Akademik 2022/2023

No Pendaftaran :................................................................
Program Studi :................................................................
1. Nama Lengkap : ................................................................ FOTO
2. NIK : ................................................................
3. Jenis Kelamin : .......................................................................... 3x4
4. Tempat, Tanggal Lahir : ..........................................................................
5. Kewarganegaraan : ..........................................................................
6. Agama : ..........................................................................
7. Golongan Darah : ..........................................................................
8. Alamat Asal / Kode Pos : ..........................................................................
...........................................................................
9. Alamat Sekarang / Kode Pos : ..........................................................................
...........................................................................
10. Kabupaten/Kota : ..........................................................................
11. Nomor Telepon : ..........................................................................
12. Anak Ke : ..........................................................................
13. NEM / NIM / IPK : ..........................................................................
14. Nilai Ijazah Total : ..........................................................................
15. Nilai Ijazah SMU/SMK : ..........................................................................
16. Asal Sekolah : ..........................................................................
17. Alamat Sekolah / PT : ..........................................................................
18. Ukuran Baju (S/M/L/XL) : ..........................................................................
 KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN,
RISET, DAN TEKNOLOGI
POLITEKNIK NEGERI PONTIANAK
Jalan Jenderal Ahmad Yani - Pontianak 78124, Kalimantan Barat
Telepon: (0561)736180, Faksimile: (0561) 740143, Kotak Pos 1286
Laman: www.polnep.ac.id

Biodata Orang Tua / Wali

1. Nama Ayah : ...................................................................................

2. Tempat Tanggal Lahir : ...................................................................................
3. Pekerjaan Ayah : ...................................................................................
4. Penghasilan Ayah Per Bulan : ...................................................................................
5. Nama Ibu : ...................................................................................
6. Tempat Tanggal Lahir : ...................................................................................
7. Pekerjaan Ibu : ...................................................................................
8. Penghasilan Ibu Per Bulan : ...................................................................................
9. Jumlah Anak : ...................................................................................
10. Alamat Orang Tua / Kode Pos : ...................................................................................
....................................................................................
11. Kabupaten / Kota : ...................................................................................
12. Nomor Telepon Orang Tua : ...................................................................................
13. Nama Wali : ...................................................................................
14. Pekerjaan Wali : ...................................................................................
15. Alamat Wali / Kode Pos : ...................................................................................
....................................................................................
16. Kabupaten / Kota : ...................................................................................
17. Nomor Telepon Wali : ...................................................................................

Saya menyatakan data yang saya isikan adalah benar.

**Coret yang tidak perlu

Pontianak, 2022
Calon Mahasiswa Baru

( )

Catatan : Calon Mahasiswa Baru wajib melampirkan :

- Fotocopy Ijazah terakhir
- Fotocopy KTP Orang Tua/Wali
- Fotocopy Kartu Keluarga (KK)