D12523.........

DATA DIRI MAHASISWA

I. PERSONAL DATA
1. Nama Lengkap
2. Nama Kecil
3. Tempat/Tgl/Lahir
4. Alamat
5. No. Telepon
6. Jumlah Saudara
7. Agama
8. Golongan Darah
: ...........................................................................................
: ……………………………………………………………
: ……………………………………………………………
: ……………………………………………………………
……………………………………………………………
: ……………………./HP. : ................................................
: ............................................................................................
: ............................................................................................
: ............................................................................................

II. PENDIDIKAN
9. SD : ......................................tahun lulus : ......................................
10. SMP : ......................................tahun lulus : ......................................
11. SMA/SMK/MA: ...................................tahun lulus : .......................................
12. Prestasi yang pernah diraih :
a. Sekolah : ............................................................................................
............................................................................................
b. Luar Sekolah : ............................................................................................
............................................................................................
13. Pengalaman Berorganisasi:
a. Sekolah : ............................................................................................
............................................................................................
 b. Luar Sekolah : ............................................................................................
............................................................................................
14. Pengalaman Bekerja: ........................................................................................
15. Sakit berat yang pernah diderita: .....................................................................
16. Sakit yang kadang Kambuh: ............................................................................
17. Hobi : ..................................................................................................

III. DATA ORANG TUA

1. Nama Ayah/Wali : ...........................................................................................
2. Tempat/Tgl/Lahir : ...........................................................................................
3. Alamat : ..................................................................................................
4. No. Telepon : .................................................................................................
5. Pendidikan Terakhir: .......................................................................................
6. Pekerjaan Beri Silang (X)
a. Guru ( ______ )
b. TNI/Polisi ( ______ )
c. Pedagang ( ______ )
d. Petani ( ______ )
e. PNS/BUMN ( ______ )
f. Wiraswasta ( ______ )
g. Lain-Lain sebutkan) : ....................................................................................
7. Penghasilan per bulan : ....................................................................................
8. Nama Ibu : ..................................................................................................
9. Tempat/Tgl/Lahir : ............................................................................................
10. Alamat : ..................................................................................................
..................................................................................................
11. No. Telepon : ..................................................................................................
12. Pendidikan Terakhir : ......................................................................................
13. Pekerjaan Beri Silang (X)
a. Guru ( _______ )
b. TNI/Polisi ( _______ )
c. Pedagang ( _______ )
d. Petani ( _______ )
e. PNS/BUMN ( _______ )
f. Wiraswasta ( _______ )
g. Lain-lain (sebutkan) : ...................................................................................
14. Penghasilan per bulan : ...................................................................................

Cilegon, ______ Desember 2023

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Tanda tangan & nama jelas