SEKOLAH TINGGI ILMU KOMPUTER

STIKOM TUNAS BANGSA PEMATANGSIANTAR

SK MENDIKBUD RI NO.408/E/0/2014 Tanggal 11 September 2014
PROGRAM STUDI SISTEM INFORMASI

BIODATA MAHASISWA
TAHUN AKADEMIK 2020 / 2021

1. DATA MAHASISWA
1.1. NIM *( Wajib Diisi ) : .....................................................................................................................................................
1.2. Nama * (sesuai dengan ijazah) : ...................................................................................................................................................
1.3. Tempat & Tanggal Lahir : ....................................................................................................................................................
1.4. Agama : Islam Kristen Protestan Kristen Khatolik
Hindu Budha
1.5. Jenis Kelamin : Pria Wanita
1.6. Anak ke : ...................................................................................................................................................
1.7. Golongan Darah : A B AB O
1.8. NIK ( Nomor Induk Kependudukan )* : ...................................................................................................................................................

1.9. Jenis Tinggal : Ikut Orang Tua Rumah Sendiri

1.10. Nama Ibu *( Wajib Diisi ) : ...................................................................................................................................................
1.10. Alamat Lengkap :
1.10.1. Jalan : .....................................................................................................................................................
1.10.2. RT/RW : .....................................................................................................................................................
1.10.3. Desa/Kelurahan : .....................................................................................................................................................
1.10.4. Kecamatan : .....................................................................................................................................................
1.10.5. Kabupaten/Kota : .....................................................................................................................................................
1.10.6. Provinsi : .....................................................................................................................................................
1.10.7. Kode Pos :.....................................................................................................................................................
1.11. No. Telp/Hp : .....................................................................................................................................................
1.12. E-mail : .....................................................................................................................................................
1.13. Status : Aktif Cuti Non Aktif DO
1.14. Tanggal Masuk : .....................................................................................................................................................
1.15. Semester : 1 2 3 4 5 6 7 8
1.16. Program Studi : Teknik Informtika (TI) Sistem Informasi (SI)
1.17. Status Mahasiswa : Baru
Asal Sekolah SMA/SMK : ................................................................................
Tahun Tamat : ................................................................................
Pindahan / Transfer
Kode Perguruan Tinggi Asal : ................................................................................
Nama Perguruan Tinggi : ................................................................................
NIM Asal : ................................................................................
Program Studi Asal : ................................................................................
Jenjang Pendidikan : ................................................................................
Tanda( * ) Wajib diisi, mohon diisi dengan data yang sebenar - benarnya

Jln. Jend.Sudirman Blok A No.1-3 Pematangsiantar – 21127 Telp. (o622) 22431 Fax. (0622) 7436800
2. DATA ORANG TUA
2.1. Nama ayah : .....................................................................................................................................................
2.2. Tempat Lahir : .....................................................................................................................................................
2.3. Tanggal Lahir : .....................................................................................................................................................
2.4. Pendidikan Terakhir : .....................................................................................................................................................
2.5. Pekerjaan Ayah : .....................................................................................................................................................
2.6. Instansi Ayah : .....................................................................................................................................................
2.7. Penghasilan : Rp. .................................. / bulan
2.8. Nama Ibu : .....................................................................................................................................................
2.9. Tempat Lahir : .....................................................................................................................................................
2.10. Tanggal Lahir : .....................................................................................................................................................
2.11. Pendidikan Terakhir : .....................................................................................................................................................
2.12. Pekerjaan Ibu : .....................................................................................................................................................
2.13. Instansi Ibu : .....................................................................................................................................................
2.14. Penghasilan : Rp. .................................. / bulan
2.15. Alamat Orang Tua : .....................................................................................................................................................
2.16. No. Telp./HP Ayah : .....................................................................................................................................................
2.17. No. Telp./HP Ibu : .....................................................................................................................................................

3. DATA WALI
3.1. Nama Wali : .....................................................................................................................................................
3.2. Tempat Lahir Wali : .....................................................................................................................................................
3.3. Tanggal Lahir Wali : .....................................................................................................................................................
3.4. Alamat Wali : .....................................................................................................................................................
3.5. Pendidikan Terakhir Wali : .....................................................................................................................................................
3.6. Pekerjaan Wali : .....................................................................................................................................................
3.7. Penghasilan : Rp. .................................. / bulan
3.8. No.Telp./HP : .....................................................................................................................................................

4. MEDIA SOSIAL
4.1. Facebook : .....................................................................................................................................................
4.2. Twitter : .....................................................................................................................................................
4.3. Instagram : .....................................................................................................................................................
4.4. Google Map : .....................................................................................................................................................

Jln. Jend.Sudirman Blok A No.1-3 Pematangsiantar – 21127 Telp. (o622) 22431 Fax. (0622) 7436800
5. DATA KEBUTUHAN KHUSUS *
5.1. Mahasiswa
A. Tunas Netra D. Tuna Daksa Ringan G. Hiper Aktif K. Narkoba
B. Tuna Rungu D1. Tunas Daksa Sedang H. Cerdas Istimewa L. Indigo
C. Tuna Grahita Ringan E. Tuna Laras I. Bakat Istimewa M. Down Sindrom
C1. Tuna Grahita Sedang F. Tuna Wicara J. Kesulitan Belajar N. Autis

5.2. Ayah
A. Tunas Netra D. Tuna Daksa Ringan G. Hiper Aktif K. Narkoba
B. Tuna Rungu D1. Tunas Daksa Sedang H. Cerdas Istimewa L. Indigo
C. Tuna Grahita Ringan E. Tuna Laras I. Bakat Istimewa M. Down Sindrom
C1. Tuna Grahita Sedang F. Tuna Wicara J. Kesulitan Belajar N. Autis

5.3. Ibu
A. Tunas Netra D. Tuna Daksa Ringan G. Hiper Aktif K. Narkoba
B. Tuna Rungu D1. Tunas Daksa Sedang H. Cerdas Istimewa L. Indigo
C. Tuna Grahita Ringan E. Tuna Laras I. Bakat Istimewa M. Down Sindrom
C1. Tuna Grahita Sedang F. Tuna Wicara J. Kesulitan Belajar N. Autis

5.4. Wali
A. Tunas Netra D. Tuna Daksa Ringan G. Hiper Aktif K. Narkoba
B. Tuna Rungu D1. Tunas Daksa Sedang H. Cerdas Istimewa L. Indigo
C. Tuna Grahita Ringan E. Tuna Laras I. Bakat Istimewa M. Down Sindrom
C1. Tuna Grahita Sedang F. Tuna Wicara J. Kesulitan Belajar N. Autis

*) Berikan Tanda Checklist ( √ ) pada kolom sebelah kiri pilihan

6. LAMPIRAN
6.1. Lampiran Data Diri
No Jenis Lampiran Status
1 Fotokopi Ijazah SMA/SMK atau sederajat yang di leges
2 Fotokopi Kartu Keluarga (KK)
3 Fotokopi Akte Kelahiran
4 Fotokopi Kartu Tanda Penduduk (KTP)
5 Fotokopi Kartu Tanda Mahasiswa (KTM)

Pematangsiantar, .........................................
Pas Photo Dibuat Oleh,
3x4 cm
Warna

..................................................................................
NIM :

Jln. Jend.Sudirman Blok A No.1-3 Pematangsiantar – 21127 Telp. (o622) 22431 Fax. (0622) 7436800