FORMULIR UNTUK PENGISIAN DATA PDDIKTI

Nama Mahasiswa :...................................................................................................................

Tempat dan Tanggal Lahir :............................................................................................
Nomor Pokok Mahasiswa (NPM) :.................................................................................
Agama :...........................................................................................................................
Nomor Induk Kependudukan (NIK)*:............................................................................
Alamat* :....................................................................................................................................
Dusun* :.....................................................................................................................................
RT : RW :
Kelurahan* :...............................................................................................................................
Kodepos :
Kecamatan* :.............................................................................................................................
Kab/Kota* :................................................................................................................................
Provinsi :
Jenis Tinggal : Rumah Sendiri/Kost/Tinggal Dengan Keluarga (Wali)**
Jika Kost/Tinggal Dengan Keluarga (Wali) :
Alamat* :...............................................................................................................
Dusun* :...........................................................................................................................
RT : RW :
Kelurahan* :....................................................................................................................
Kodepos :
Kecamatan* :...................................................................................................................
Kab/Kota* :.....................................................................................................................
Provinsi :
Telepon :.....................................................................................................................................
Handphone :
Email :.............................................................................................................................
Kebutuhan Khusus :........................................................................................................
Nama Ayah :.............................................................................................................................
Nomor Induk Kependudukan (NIK) :.............................................................................
Tempat dan Tanggal Lahir :............................................................................................
Pekerjaan :.......................................................................................................................
Penghasilan :...................................................................................................................
Pendidikan :....................................................................................................................
Kebutuhan Khusus :........................................................................................................
Nama Ibu :................................................................................................................................
Nomor Induk Kependudukan (NIK):..............................................................................
Tempat dan Tanggal Lahir :............................................................................................
Pekerjaan :.......................................................................................................................
Penghasilan :...................................................................................................................
Pendidikan :....................................................................................................................
Kebutuhan Khusus :........................................................................................................
Nama Wali :..............................................................................................................................
Nomor Induk Kependudukan (NIK) :.............................................................................
Tempat dan Tanggal Lahir :............................................................................................
Pekerjaan :.......................................................................................................................
Penghasilan :...................................................................................................................
Pendidikan :....................................................................................................................
Kebutuhan Khusus :........................................................................................................
Penerima KPS ( Kartu Perlindungan Sosial ) Ya Tidak
No. KPS :..................................................................................................................................

Mengetahui :
Orang Tua/Wali Mahasiswa Yang Membuat Pernyataan,

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

Keterangan: * : Isi sesuai KTP atau Kartu Keluarga

** : Coret yang tidak perlu
Foto Copy 1 (Satu) Lembar