Post on 22-May-2019
UNIVERSITAS ISLAM
MALANG
Kode : 05/FORM/PEND/PPM/IX/2016
Tanggal : 8 September 2016
FORMULIR BIODATA ALUMNI
MAHASISWA
Revisi : 0
Halaman : 1 dari 2
FORMULIR BIODATA ALUMNI MAHASISWA UNIVERSITAS ISLAM MALANG
Proses Penanggungjawab
Tanggal Nama Jabatan Tanda Tangan
1. Perumusan Dr. Ir. Mahayu Woro Lestari,MP. Ketua Tim
8-9-2016
2. Pemeriksaan Dr. Ir. Mahayu Woro Lestari,MP Ketua PPM 8-9-2016
3. Persetujuan Prof. Junaidi, M.Pd.,Ph.D WR 1
8-9-2016
4. Penetapan Prof. Maskuri,M.Si. Rektor
8-9-2016
5. Pengendalian Dr. Ir. Mahayu Woro Lestari,MP PPM
8-9-2016
BIODATA ALUMNI MAHASISWA UNIVERSITAS ISLAM MALANG
1. N a m a : ...............................................................................
2. N P M : ...............................................................................
3. Tempat, tanggal lahir : ...............................................................................
4. Fakultas / Program Studi : ...............................................................................
5. Alamat Asal / Rumah : Jalan ......................................................................
(bukan alamat kos) Gg. .........................................................................
No ..........................................................................
RT / RW ................................................................
Desa ......................................................................
Kelurahan...............................................................
Kecamatan .............................................................
Kabupaten / Kota *) ................................................
Propinsi ..................................................................
Nomor Telepon ......................................................
Alamat Email ..........................................................
Akun Facebook ......................................................
6. Nama Bapak : ...............................................................................
7. Nama Ibu : ...............................................................................
8. Alamat Orang Tua/Wali : Jalan ......................................................................
Gg. .........................................................................
No ..........................................................................
RT / RW ................................................................
Dusun ....................................................................
Desa/Kelurahan *) ..................................................
Kecamatan .............................................................
Kabupaten / Kota *) ................................................
Propinsi ..................................................................
9. Nomor Telepon Orang Tua : ...............................................................................
10. Nomor Telepon Saudara yang bisa dihubungi
: ...............................................................................
Demikian biodata ini saya buat dengan sebenarnya, dan apabila ada kesalahan saya bertanggung jawab sepenuhnya.
Malang,
*) coret yang tidak perlu
MOHON PENGISIAN FORM BIODATA ALUMNI DIKETIK SECARA BENAR DAN LENGKAP DENGAN TIDAK MERUBAH URUTAN DAN ISINYA
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