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UNIT KEGIATAN MAHASISWA

BASMALA UNIMEN
BARISAN MAHASISWA PENCINTA ALAM UNIVERSITAS MUHAMMADIYAH ENREKANG
Alamat ; JL. JendralSudirman, Galonta, Kec. Enrekang, KabupatenEnrekang, Sulawesi Selatan 91711.
Tlp; 087755417956
E-mail : basmalaunimen@gmail.com

FORMULIR PENDAFTARAN CALON ANGGOTA

A. Data Pribadi
Nama :.............................................................................
Tempat Tanggal Lahir :.............................................................................
Agama :.............................................................................
Fakultas :.............................................................................
Jurusan :.............................................................................
Nim :.............................................................................
Alamat/Tempat Tinggal :.............................................................................
Telp/Hp :.............................................................................
Jenis Kelamin :.............................................................................
Hobi :.............................................................................
Penyakit yang diderita :.............................................................................
Pengalaman Organisasi :.............................................................................
Motivasi Masuk BASMALA :.............................................................................
…………………………………………………..

B. Data Orang Tua


Ayah :.............................................................................
Pekerjaan :.............................................................................
Alamat :.............................................................................
Telp/Hp :.............................................................................
Ibu :.............................................................................
Pekerjaan :.............................................................................
Alamat :.............................................................................

Enrekang…..,……,2023
Hormat saya

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