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 :......................................................................................................................................
Tempat Tanggal Lahir :......................................................................................................................................
Jenis Kelamin :......................................................................................................................................
Status Perkawinan :......................................................................................................................................
Nama Suami/Istri :......................................................................................................................................
Asal SLTA/Th. Lulus :......................................................................................................................................
Jurusan di SLTA :......................................................................................................................................
Alamat Selama Kuliah :......................................................................................................................................
........................................................................................................................................
No. KTP :......................................................................................................................................
Tlp./HP :......................................................................................................................................
Rekomendasi PAC GP Ansor :......................................................................................................................................
Pendidikan Pesantren :......................................................................................................................................
Pengalaman Organisasi :......................................................................................................................................
Pengalaman Kerja :......................................................................................................................................

DATA ORANG TUA

Ibu Kandung :......................................................................................................................................
Bapak Kandung :......................................................................................................................................
Alamat Rumah :......................................................................................................................................
........................................................................................................................................
Tlp./HP :......................................................................................................................................
Pendidikan Tertinggi : Ayah…………………….................…Ibu..................................................................
Pekerjaan : Ayah……………………….................Ibu..................................................................
Penghasian /bulan : Ayah……………………….................Ibu..................................................................
Nama Wali (Jika ada) :......................................................................................................................................
Pendidikan Tertinggi : Wali..............................................................................................................................
Pekerjaan : Wali ………………………………………… Penghasilan/bulan........................................
Alamat Wali :......................................................................................................................................
........................................................................................................................................
Tlp./HP :......................................................................................................................................
Hubungan dengan Wali :......................................................................................................................................

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dengan tetap mematuhi ketentuan dan peraturan yang berlaku.

Sukabumi.....................................
Pemohon/Mahasiswa tsb. di atas

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