FORMULIR PENDAFTARAN

PROGRAM BEASISWA
KULIAH KELAS KHUSUS ANSOR
STAI AL-MASTHURIYAH - SUKABUMI
JURUSAN KOMUNIKASI PENYIARAN ISLAM (KPI)
TAHUN AKADEMIK 2022/2023

DATA CALON MAHASISWA

Nama Lengkap : M. Aden Faisal..............................................................................................................
Tempat Tanggal Lahir : Sukabumi, 04-01-2004.................................................................................................
Jenis Kelamin : Laki-laki........................................................................................................................
Status Perkawinan : Belum Kawin................................................................................................................
Nama Suami/Istri :......................................................................................................................................
Asal SLTA/Th. Lulus : SMK YPM CIDAHU/ 2021/2022....................................................................................
Jurusan di SLTA : MP................................................................................................................................
Alamat Selama Kuliah :......................................................................................................................................
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No. KTP : 3202170301040006.....................................................................................................
Tlp./HP : 081224801586.............................................................................................................
Rekomendasi PAC GP Ansor : Dr. saepul falah, MPd...................................................................................................
Pendidikan Pesantren :......................................................................................................................................
Pengalaman Organisasi : Anggota Banser............................................................................................................
Pengalaman Kerja :......................................................................................................................................

DATA ORANG TUA

Ibu Kandung :Pipit...............................................................................................................................
Bapak Kandung :Alm. Ujang Herman.......................................................................................................
Alamat Rumah :Kp.Bondol......................................................................................................................
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Tlp./HP :0857-9842-1028............................................................................................................
Pendidikan Tertinggi : Ayah………………Sd…….............…Ibu Sd............................................................
Pekerjaan : Ayah……………………….................Ibu Karyawan..............................................
Penghasian /bulan : Ayah……………………….................Ibu 2.800.000..............................................
Nama Wali (Jika ada) :......................................................................................................................................
Pendidikan Tertinggi : Wali .............................................................................................................................
Pekerjaan : Wali……………………………………… Penghasilan/bulan............................................
Alamat Wali :......................................................................................................................................
........................................................................................................................................
Tlp./HP :......................................................................................................................................
Hubungan dengan Wali :......................................................................................................................................

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