FORMULIR PENDAFTARAN STAFF HIMA D3KKIM FTI-ITS 2012-2013

Nama Lengkap : ...................................................................................................Nama Panggilan : ...................................................................................................NRP : ...................................................................................................Tempat tanggal lahir : ...................................................................................................Agama : ...................................................................................................Alamat asal : ...................................................................................................Alamat Surabaya : ...................................................................................................No. Hp : ...................................................................................................E-mail : ...................................................................................................IPK : ...................................................................................................Motto Hidup : .............................................................................................................................................................................................................................................

Bakat dan keterampilan (boleh lebih dari 1)a) organisasib) menulis (karya tulis/jurnalistik)c) desaind) olah raga

e) kewirausahaanf) senig) dll, sebutkan .......................

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Proker HIMA D3KKIM yang anda ketahui1. ...........................................................................2. ...........................................................................3. ...........................................................................4. ...........................................................................5. ...........................................................................

Transportasi sehari-hari : ......................................................Bahasa sehari-hari : ......................................................

Pilihan Bidang sesuai dengan minat & bakat anda :

Bidang Akademik dan Kesejahteraan Mahasiswa

Bidang Pengembangan Sumber Daya Mahasiswa

Bidang Keprofesian dan Keilmiahan

Bidang Dalam Negeri

Bidang Hubungan Masyarakat

Bidang Kewirausahaan

*angka 1 prioritas tertinggi, angka 6 prioritas terendah

Alasan memilih bidang tersebut pada prioritas utama :..............................................................................................................................................................................................................................................................................................................................................................................................................................

Motivasi masuk ke HIMA D3KKIM FTI-ITS :..............................................................................................................................................................................................................................................................................................................................................................................................................................

Deskripsi diri : ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Komitmen ketika menjadi staf HIMA D3KKIM FTI-ITS 2012-2013 :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Pas Photo

4 x 6

Surabaya, Juli 2012

Pendaftar

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Formulir bisadiperbanyak sendiri

(difotokopy)

SURAT PERNYATAAN

Yang bertanda tangan di bawah ini:

Nama lengkap : NRP :

menyatakan bahwa saya sanggup menjalankan semua proker dan mentaati semua aturan HIMA D3KKIM FTI-ITS 2012-2013.

Demikian surat pernyataan ini saya buat. Atas perhatiannya saya mengucapkan terima kasih.

Surabaya , Juli 2012

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