2015. Formulir Biodata Mahasiswa KKN
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B I O D A T A
MAHASISWA PESERTA KKN UNAND
TAHUN AKADEMIK 2014/2015
Nomor :
I. KHUSUS
1. Nama : ....................................................................................................
2. Nomor BP : ....................................................................................................
3. Tempat / Tgl. Lahir : ........................................../.........................................................
4. Jenis Kelamin : ....................................................................................................
5. Agama : ....................................................................................................
6. Fakultas : ....................................................................................................
7. Jurusan / Prog. Studi : ........................................../.........................................................
8. Semester ke : ....................................................................................................
9. Negeri Asal : ....................................................................................................
10. S t a t u s : Belum kawin / kawin / janda / duda *)
11. Pekerjaan : Mhs. Reguler / Mhs. Non-Reguler / PNS / Peg. Swasta *)
II. U M U M
1. Asal SLTA : ..................................................................
2. Tamat SLTA Tahun : ..................................................................
3. Masuk Univ. Andalas Tahun : ..................................................................
4. Jika pindah dari Perguruan
Tinggi lain sebutkan perguruan
Tinggi tsb. : ..................................................................
III. LAIN-LAIN
1. Organisasi Ekstra yang pernah diikuti : ....................................................................
2. Organisasi Intra (SEMA, MENWA,dll) : ....................................................................
3. H o b b i : ....................................................................
4. Penyakit yang pernah diderita
(Sebutkan dengan jelas, terutama
Penyakit yang agak berat/kronis) : ....................................................................
5. Alamat anda terdekat (di Padang jika
Sewaktu-waktu perlu dihubungi : ....................................................................
6. Orang Tua / Wali :
a. Nama : .................................................................................
b. U m u r : .................................................................................
c. Agama : .................................................................................
d. Pendidikan terakhir : .................................................................................
e. Pekerjaan terakhir : .................................................................................
f. Alamat / Telpon : .................................................................................
Padang, ....................20... Saya yang mendaftar,
Catatan :
*) Coret yang tidak perlu. Harap diisi dengan huruf balok/diketik ( )
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