KEMENTRIAN PENDIDIKAN, KEBUDAYAAN

RISET DAN TEKNOLOGI

UNIVERSITAS SILIWANGI
UNIT KEGIATAN MAHASISWA PENCAK SILAT
Gedung Tri Gatra Universitas Siliwangi
Telepon: 085233033376 E-Mail: pencaksilatunsil1819@gmail.com

FORMULIR PENDAFTARAN
ANGGOTA BARU UKM PENCAK SILAT
PERIODE 2023

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

Foto Terbaru
NPM : ......................................................................................................
Angkatan : Berwarna
......................................................................................................
Tempat / Tanggal Lahir : ......................................................................................................
4x6
Jenis Kelamin : ......................................................................................................
Agama : ......................................................................................................
Alamat Lengkap Asal : ......................................................................................................
......................................................................................................
Alamat Sekarang : ......................................................................................................
Nomor HP : ......................................................................................................
Email : ......................................................................................................
Media Sosial : ......................................................................................................
Hobby :........................................................................................................
Motto Hidup :........................................................................................................
Cita-cita :........................................................................................................

Riwayat Pendidikan
SD/Sederajat : .......................................................................................................
SMP/Sederajat : .......................................................................................................
SMA/Sederajat : .......................................................................................................
Universitas :........................................................................................................
Lain-lain : …...................................................................................................
Riwayat Organisasi
1. ..........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
Riwayat Prestasi

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

Tasikmalaya,......................2023

( .......................................)

NPM ..............................