BIODATA MAHASISWA

PRODI SARJANA TERAPAN TEKNOLOGI LABORATORIUM MEDIS

JURUSAN TEKNOLOGI LABORATORIUM MEDIS
TAHUN AKADEMIK 2023/2024

NAMA LENGKAP : ...................................................

NAMA PANGGILAN : ...................................................
NIM : ................................................... Foto 3x4
PROGRAM STUDI : ...................................................
TEMPAT, TANGGAL LAHIR : ...................................................
AGAMA : ...................................................
ASAL SEKOLAH /TAHUN LULUS : .........................................................................
ALAMAT DOMISILI
Jalan/No. Rumah :.................................................................................
Kelurahan/Desa/Kecamatan :.................................................................................
Kabupaten/Kota/Provinsi :.................................................................................
Status Alamat (Kost / tempat pribadi / dll)* :....................................................
No. Telpon/HP/WA : .........................................................................
Email : .........................................................................
Status Menikah : ( Sudah Menikah / Belum Menikah )*
Jumlah Saudara Kandung : .........................................................................
Kegemaran/Hobi : .........................................................................
Organisasi yang Pernah Diikuti : .........................................................................
Prestasi yang Pernah Diperoleh : .........................................................................
BIODATA ORANG TUA/WALI
Nama Ayah/Wali : .........................................................................
Pekerjaan : .........................................................................
Penghasilan perbulan : .........................................................................
Alamat Orang Tua/Wali : .........................................................................
...................................Kode Pos......................
No. Tlp Orang Tua/Wali : .........................................................................
Alasan Masuk TLM : ..........................................................................
Moto Hidup : ..........................................................................
..........................................................................

Mengetahui,

)* Coret yang tidak perlu ( )