Formulir Pendaftaran Beastudi Etos 2014
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BIODATA CALON PESERTA BEASTUDI ETOS 2014 No, Registrasi Peserta : ............................................................................................................... Tahun Masuk Etos : ............................................................................................................... DATA DIRI PENDAFTAR Nama Peserta : ............................................................................................................... Jenis Kelamin : ............................................................................................................... Tinggi / berat badan : ............................................................................................................... Hobi / kegemaran : ............................................................................................................... Penyakit yang pernah diderita : ................................................................................................... Golongan darah : ............................................................................................................... Asal suku : ............................................................................................................... Nomor Hp : ............................................................................................................... Asal SMA : ............................................................................................................... Alamat email : ............................................................................................................... Alamat asal Nama jalan : ............................................................................................................... ............................................................................................................... Kelurahan : ............................................................................................................... Kecamatan : ............................................................................................................... Kebupaten : ............................................................................................................... Propinsi : ............................................................................................................... No. Telepon : ............................................................................................................... Keterangan Telepon : milik pribadi / milik saudara / milik tetangga * (wajib diisi) atas nama ................................................................................................................................... Jarak antara alamat saat ini dan tempat daftar : ..................KM Alamat sekarang ( diisi jika tidak sama dengan alamat asal ) Nama jalan : ............................................................................................................... ............................................................................................................... Kelurahan : ............................................................................................................... Kecamatan : ............................................................................................................... Kebupaten : ............................................................................................................... Propinsi : ............................................................................................................... No. Telepon : ............................................................................................................... Keterangan Telepon : milik pribadi / milik saudara / milik tetangga * (wajib diisi) atas nama ...................................................................................................................................
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Formulir Pendaftaran Beastudi Etos 2014
Transcript of Formulir Pendaftaran Beastudi Etos 2014
BIODATA CALON PESERTA BEASTUDI ETOS 2014
No, Registrasi Peserta : ...............................................................................................................
Tahun Masuk Etos : ...............................................................................................................
DATA DIRI PENDAFTAR
Nama Peserta : ...............................................................................................................
Jenis Kelamin : ...............................................................................................................
Tinggi / berat badan : ...............................................................................................................
Hobi / kegemaran : ...............................................................................................................
Penyakit yang pernah diderita : ...................................................................................................
Golongan darah : ...............................................................................................................
Asal suku : ...............................................................................................................
Nomor Hp : ...............................................................................................................
Asal SMA : ...............................................................................................................
Alamat email : ...............................................................................................................
Alamat asal
Nama jalan : ...............................................................................................................
...............................................................................................................
Kelurahan : ...............................................................................................................
Kecamatan : ...............................................................................................................
Kebupaten : ...............................................................................................................
Propinsi : ...............................................................................................................
No. Telepon : ...............................................................................................................
Keterangan Telepon : milik pribadi / milik saudara / milik tetangga * (wajib diisi)
atas nama ...................................................................................................................................
Jarak antara alamat saat ini dan tempat daftar : ..................KM
Alamat sekarang ( diisi jika tidak sama dengan alamat asal )
Nama jalan : ...............................................................................................................
...............................................................................................................
Kelurahan : ...............................................................................................................
Kecamatan : ...............................................................................................................
Kebupaten : ...............................................................................................................
Propinsi : ...............................................................................................................
No. Telepon : ...............................................................................................................
Keterangan Telepon : milik pribadi / milik saudara / milik tetangga * (wajib diisi)
atas nama ...................................................................................................................................
DATA KELUARGA ( Wajib diisi )
No. Nama Status Dalam
Keluarga
Umur Pekerjaan Jumlah Penghasilan *
(wajib diisi)
1
2
3
4
5
6
7
Anak ke …… dari ………. bersaudara ( Wajib diisi )
Apakah ada anggota keluarga yang pernah menerima Beasiswa SMART/ Beastudi Etos ?
…………………………………………………………………………………………… Penyokong pendapatan lainnya (selain saudara kandung)
Nama : ...............................................................................................................
Pekerjaan : ................................. (sebutkan jenis pekerjaan dengan lebih spesifik)
Umur : ...............................................................................................................
Hubungan dengan anda : …...............................................................................................
Jumlah penghasilan / bulan (sebutkan nominalnya) : ................................................................
Jumlah pendapatan yang diberikan : …...................................................................................
Jumlah tanggunganya : …...................................................................................
No. Telp / Hp yang dapat dihubungi : …...................................................................................
Kecerdasan Sosial Pendaftar
a) Jelaskan pendapat anda tentang keluarga anda
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
b) Tuliskan & deskripsikan tentang sahabat akrab anda
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
c) Jelaskan kondisi ekonomi keluarga
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
DATA PRESTASI
Akademik / Sekolah
No. Bidang Perlombaan Peringkat / Rangking
1
2
3
4
5
6
Prestasi Luar Sekolah
No. Nama Lomba Ruang Lingkup (Kec / Kab /
Prop / Nas / Inter) Peringkat
1
2
3
4
5
6
7
PENGALAMAN ORGANISASI
No. Nama Organisasi Jabatan Tahun
Kepengurusan
1
2
3
4
5
6
7
HAL KHUSUS
Kegiatan pasca lulus SMA : ...................................................................................................
Tahun masuk kuliah : ...................................................................................................
Tujuan dan harapan mengikuti program : ….......................................................................
Universitas / Fakultas / Jurusan yang dituju
Pilihan 1 (Wajib diisi )
Universitas : ...................................................................................................
Fakultas : ...................................................................................................
Jurusan : ...................................................................................................
Pilihan 2 (Wajib diisi )
Universitas : ...................................................................................................
Fakultas : ...................................................................................................
Jurusan : ...................................................................................................
Pilihan 3 (jika memilih IPC)
Universitas : ...................................................................................................
Fakultas : ...................................................................................................
Jurusan : ...................................................................................................
Kelebihan diri : ...................................................................................................
Kelemahan diri : ...................................................................................................
Cita-cita
- 1 Tahun mendatang : ...........................................................................
- 5 Tahun mendatang (setelah lulus kuliah) : ...........................................................................
- 10 Tahun mendatang : ...........................................................................
Motto hidup : ...........................................................................
............................................................................
Buku bacaan favorit : ...........................................................................
Tokoh pemimpin idola : ...........................................................................
Kesuksesan yang pernah diraih / dirasakan : ...........................................................................
Tuliskan karangan singkat tentang kisah hidup anda dari kecil sampai sekarang (Sekurang-
kurangnya 1 Halaman Folio )
……………………………… , ……………
(……………………………………)
ket* : coret yang tidak perlu
