7/26/2019 Form Biodata Registrasi Ulang SPMB

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KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

UNIVERSITAS SULTAN AGENG TIRTAYASA

PPAASSCCAASSAARRJJAANNAAJl. Raya Jakarta Km. 04 Pakupatan Serang

Telepon : (0254) 280330, Ext 204 Fax. (0254) 281254

BIODATA MAHASISWA BARU PASCASARJANA

FORM REGISTRASI

Petunjuk : Isilah data dengan lengkap dan benar

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No. HP / Email : ............................................/................................................

Pendidikan Terakhir : Gelar Akademik : ...............................................................

IPK : ...............................................................

Program Studi : ...............................................................

Tahun Lulus : ...............................................................

Universitas : ...............................................................

Pekerjaan : .............................................................................................

Instansi Tempat Bekerja : .............................................................................................

Jabatan : .............................................................................................

Golongan Darah : .............................................................................................

Nama Ibu Kandung : .............................................................................................

Nama Ayah Kandung : .............................................................................................

Serang, ................................

Mahasiswa,

(..........................................)

Pas foto

3 x 4berwarna

Nama Lengkap : .............................................................................................

No. Test : .............................................................................................

Program Studi Pilihan : ....................................Konsentrasi........................................

Tempat, Tanggal Lahir : ......................................./....................................................

Jenis Kelamin / Agama : ......................................./....................................................

Alamat Rumah (Lengkap) : .............................................................................................

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