Penerimaan Mahasiswa Baru

MUHA
AS M
IT

M
S
UNIVER

AD
I YA H
UNIVERSITAS MUHAMMADIYAH BANJARMASIN Pas Foto
Tahun Ajaran 20 / 20 3x4

FORMULIR
1. Program : Reguler ODS PA PNA PBUM
2. Nama Lengkap (sesuai Akta lahir) : ..............................................................................................................................
3. Jenis Kelamin : L P Agama : ...................................................
4. Tempat Lahir (sesuai akta lahir) : ............................................... Tanggal Lahir :
5. Alamat Rumah (sesuai KK) : Jl .........................................................................................................................
: Kec. ...................................................... Kab. .....................................................
Prov. .................................................... Kode Pos .............................................
No. Telp/Hp & Email Pendaftar : E-mail : .................................................
No. Induk Kependudukan (NIK)
6. Nama Orang Tua/Wali : Ayah : ...................................................... ibu : .................................................
Pekerjaan Orang Tua/Wali : .................................................................. : .................................................
Alamat Orang Tua/Wali : ..............................................................................................................................
.................................................. No. HP :
7. Asal Sekolah : ..............................................................................................................................
Propinsi/Kabupaten/Kota : ..............................................................................................................................
Jurusan : ..............................................................................................................................
8. Nilai Raport (untuk Pendaftar Kelas 1 Kelas 2 Kelas 3
Program Prestasi Akademik) smt 1 smt 2 smt 1 smt 2 smt 1 smt 2
Matematika
Bhs. Indoonesia
B. Inggris
Rata-rata Raport
Rangking (dari jlh siswa Kelas)

9. Pilihan (1) Fakultas : ............................................................................................................................

Prodi/Jurusan : ............................................................................................................................
10. Pilihan (2) Fakultas : ............................................................................................................................
Prodi/Jurusan : .............................................................................................................................
11. Pilihan (3) Fakultas : .............................................................................................................................
Prodi/Jurusan : .............................................................................................................................
11. Kebutuhan Khusus : .............................................................................................................................
11. Cek Kelengkapan Berkas
2 Lembar fotocopy Ijazah/SKL/Surat Keterangan Sekolah 1 Lembar Asli Surat Keterangan Sehat

2 Lembar fotocopy Transkrip Nilai (bagi S1 Kep. B) 1 Lembar fotocopy Kartu Keluarga

1 Lembar Asli Surat Keterangan Kelakuan Baik (SKKB) 1 Lembar fotocopy Akta Kelahiran

6 Lembar Pas foto ukuran 3x4 berwarna

No. Tes diisi oleh Petugas Banjarmasin, .......................................

Pendaftar

Nama & Paraf Petugas (.......................................) (....................................................)