Formulir Pendaftaran Papi 2015 Edit Fix
42
FORMULIR PENDAFTARAN PEMILIHAN PUTRA PUTRI GIZI KOTA MALANG 2015 NO PENDAFTARAN : NAMA LENGKAP : .................................................................... .................................. NAMA PANGGILAN : .................................................................... .................................. JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*) TEMPAT TANGGAL LAHIR : .................................................................... .................................. USIA : ............th, agama : ............................................................... NAMA ORANG TUA : ......................................... ............................................................. ALAMAT ASAL : .................................................................... .................................. .............................. .................................................................... .(**) ALAMAT MALANG : ......................................... ............................................................. ........................................... ............................................................. NO HP :.......................................... ............................................................. TB/BB : ................... cm., .................. kg ASAL PERGURUAN TINGGI :.......................................... ........................................................(**) JURUSAN / FAKULTAS : ......................................... ............................................................. SEMESTER : ......................................... ............................................................. 201 001
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FORMULIR PENDAFTARAN
Transcript of Formulir Pendaftaran Papi 2015 Edit Fix
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................
2015 001
3...................................................................................................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
TAHAP – TAHAP PELAKSANAAN1. Pendaftaran
a. Pendaftaran dibuka sejak tanggal 12 Oktober 2015 – 11 November 2015
b. Tempat pengumpulan formulir dan pembayaran biaya pendaftaran :HMP DIII JURUSAN GIZI POLTEKKES KEMENKES MALANGSenin – Jumat : 15.00 – 18.00 WIBCP : Izza 0857 777 37311
Robby 081 555 865 482biaya pendaftaran bisa di TRANSFER MELALUI REKENINGBANK MANDIRI A/N. NISHAR ZULMI 90000 1986 4967
2. Seleksi tulis, wawancara dan minat bakat dilaksanakan pada :Hari / Tanggal : Sabtu, 21 November 2015Waktu : 07.30 - selesaiTempat : Jurusan Gizi Poltekkes Kemenkes Malang
3. Grand Final dilaksanakan pada :Hari / Tanggal : Jumat, 27 November 2015Waktu : 18.30 – selesai
1. Laki laki / perempuan sehat jasmani dan rohani dan bebas dari penyalah gunaan NARKOBA
2. Merupakan Warga Negara Indonesia3. Usia 16-22 tahun dan belum menikah
Foto 4x6
KRITERIA PESERTA
PETUNJUK TEKNISPEMILIHAN PUTRA PUTRI GIZI KOTA MALANG 2015
Tercatat sebagai mahasiswa aktif semester 1-4 Jurusan Gizi di Universitas se-Malang Raya
4. IMT normal5. Berkepribadian dan berpenampilan menarik, berbakat dan kreatif 6. Berwawasan luas dan komunikatif7. Diutamakan mampu berkomunikasi bahasa inggris dengan baik
1. Fotocopy KTP dan KTM masing – masing 2 lembar2. Pas Foto 4x6 (2 lembar) 3. Foto berwarna terbaru (*)
a. Close Up ukuran 4R (1 lembar) b. Seluruh badan 4R (1 lembar)
4. Surat izin / rekomendasi dari Jurusan / Prodi 5. Mengisi formulir pendaftaran6. Seluruh berkas dimasukkan dalam map kertas warna biru (putra)
dan warna merah muda (putri)*dengan background foto bebas, memakai pakaian bebas, sopan dan rapi.
PERSYARATAN PENDAFTARAN
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................
2015 002
3...................................................................................................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................
Foto 4x6
2015 003
NO HP:.................................................................................
......................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
Foto 4x6
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
2015 004
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kg
Foto 4x6
2015 005
ASAL PERGURUAN TINGGI:.................................................................................
.................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
Foto 4x6
2015 006
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)
Foto 4x6
2015 007
JURUSAN / FAKULTAS: ................................................................................
......................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................
Foto 4x6
2015 008
NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................
Foto 4x6
2015 009
SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)
Foto 4x6
2015 010
TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
Foto 4x6
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................
2015 011
TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................
Foto 4x6
2015 012
NAMA ORANG TUA: ................................................................................
......................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
Foto 4x6
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
2015 013
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................
Foto 4x6
2015 014
ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
Foto 4x6
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2015 015
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)
Foto 4x6
2015 016
ALAMAT MALANG: ................................................................................
........................................................................................................
......................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
Foto 4x6
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
2015 017
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
Foto 4x6
2015 018
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARAN
Foto 4x6
PEMILIHAN PUTRA PUTRI GIZIKOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
2015 019
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI
KOTA MALANG 2015
NO PENDAFTARAN :
NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA
: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG
: ......................................................................................................
........................................................................................................NO HP
:.......................................................................................................
Foto 4x6
2015 020
TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI
:..................................................................................................(**)JURUSAN / FAKULTAS
: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................
Tingkat ..................................................................................
2. .................................................................................................
Tingkat ..................................................................................3..............................................................................
.....................
Tingkat...................................................................................
(*) pilih salah satu(**) disertai fotocopy KTP dan KTM
Malang, .....................................................
(.....................................................................)
Foto 4x6
