1. Nama : _________________________________________________________
2. NIM : __________________________________________________________
3. Kelas : _________________________________________________________
4. TTL : __________________________________________________________
5. No HP/WA : ____________________________________________________
6. Semester : ______________________________________________________
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12. Pilihan Departemen 2 : ____________________________________________
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14. Apa hal yang akan kalian lakukan jika diterima di himatika : ______________
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