PROFIL MAHASISWA

PHOTO 4X6

NAMA LENGKAP :…………………………………………………………………

NAMA PANGGILAN :…………………………………………………………………

NIM :…………………………………………………………………

PROGRAM STUDI :…………………………………………………………………

TAHUN MASUK :…………………………………………………………………

TEMPAT/ TGL LAHIR :…………………………………………………………………

JENIS KELAMIN :…………………………………………………………………

AGAMA :…………………………………………………………………

NO TELP/HP (WA) :…………………………………………………………………

EMAIL :…………………………………………………………………

ALAMAT ASAL

Jalan/No Rumah : …………………………………………………………………

Keluraham/Desa/Kecamatan : …………………………………………………………………

RT/RW : …………………………………………………………………

Kabupaten/Kota/Provinsi : …………………………………………………………………

Kode Pos : …………………………………………………………………

ALAMAT TEMPAT TINGGAL

Jalan/No Rumah : …………………………………………………………………

Keluraham/Desa/Kecamatan : …………………………………………………………………

RT/RW : …………………………………………………………………
Kabupaten/Kota/Provinsi : …………………………………………………………………

Kode Pos : …………………………………………………………………

Status Alamat : Tinggal Bersama Orang Tua/Wali/Kos/Lainnya

DATA ORANG TUA/WALI

Nama Ayah : ………………………………………………………………………….

Tanggal Lahir : ………………………………………………………………………….

Pekerjaan : ………………………………………………………………………….

Pendidikan : ………………………………………………………………………….

Alamat : ………………………………………………………………………….

No Hp : ………………………………………………………………………….

Penghasilan (<1 Juta/1-2 Juta/>2 Juta) : ………………………………………………………...

Nama Ibu : ………………………………………………………………………….

Tanggal Lahir : ………………………………………………………………………….

Pekerjaan : ………………………………………………………………………….

Pendidikan : ………………………………………………………………………….

Alamat : ………………………………………………………………………….

No Hp : ………………………………………………………………………….

Penghasilan (<1 Juta/1-2 Juta/>2 Juta) : ………………………………………………………..

Nama Wali : ………………………………………………………………………….

Tanggal Lahir : ………………………………………………………………………….

Pekerjaan : ………………………………………………………………………….

Pendidikan : ………………………………………………………………………….

Alamat : ………………………………………………………………………….

No Hp : ………………………………………………………………………….

Penghasilan (<1 Juta/1-2 Juta/>2 Juta) : ………………………………………………………...

RIWAYAT PENDIDIKAN

N TAHUN
TINGKAT ASAL SEKOLAH JURUSAN ALAMAT SEKOLAH
O LULUS
STATUS MAHASISWA

Status Menikah : Belum menikah/menikah

Anak Ke : ………………………………………………………………

Jumlah Saudara Kandung : ………………………………………………………………

BAKAT/MINAT DAN PRESTASI

Kegemaran/hobi :

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Kegiatan Ekstrakulikuler Dan Pelatihan Yang Pernah Diikuti (5 Tahun Terakhir)

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PRESTASI (5 TAHUN TERAKHIR)

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ALASAN MASUK BIDAN :

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MOTTO HIDUP :
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