FORMULIR PENDAFTARAN PBAK 2022

IAIN Lhokseumawe

BIODATA PESERTA

Nama Lengkap : ...........................................................................................................................

No. Ujian : ...........................................................................................................................
Fakultas : ........................................................................................................................... 3x4
Jurusan : ...........................................................................................................................
Tempat/Tgl. Lahir : ...........................................................................................................................
Jenis Kelamin : Laki – Laki Perempuan

Alamat : .........................................................................................................................................................
No. HP : .........................................................................................................................................................
Email : .........................................................................................................................................................
Hobby : .........................................................................................................................................................
Ukuran Baju* : S M L XL XXL *Beri Tanda Silang (X) Sesuai Ukuran

I. Jenjang Pendidikan
1. Dasar : ..................................................................................................................................................
2. Menengah : ..................................................................................................................................................
3. Atas : ..................................................................................................................................................

II. Pengalaman Organisasi

1. .................................................................................................................................................................................
2. .................................................................................................................................................................................
3. .................................................................................................................................................................................

III. Prestasi Yang Pernah Diraih

1. .................................................................................................................................................................................
2. .................................................................................................................................................................................
3. .................................................................................................................................................................................

IV. Motto Hidup

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.......................................................................................................................................................................................

Lhokseumawe, 29 Agustus 2022

( Nama dan Tanda Tangan )

Note :
1. Menyerahkan Fas Photo Warna Layar Merah :
3 x 4 = 2 lembar ( Bagi Perempuan Wajib Berjilbab)
2. Pengembalian Formulirdan berkas pada hari pertama PBAK