BIODATA CALON PESERTA

PEKAN KREATIVITAS MAHASISWA (PKM) SUMATERA III

MAHASISWA IAIN METRO
TAHUN 2023

A. Identitas Diri

Nama : .....................................................................................................

NPM : .....................................................................................................

Fakultas / Prodi : .....................................................................................................

Semester : .....................................................................................................

Tempat / Tanggal Lahir : .............................................................................................................

Jenis Kelamin : .....................................................................................................

Telpon /HP : .....................................................................................................

Alamat :......................................................................................................

Cabang yang akan diikuti : .....................................................................................................

Anggota Tim (jika kelompok) :......................................................................................................

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

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

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

B. Pengalaman Mengikuti Kejuaraan Sesuai Cabang

Tingkat Tahu
No Nama Kejuaraan Juara
Kejuaraan n
1
2
3
4
5
6
7

Metro, April 2023

Peserta,

( )
NPM.