FORMULIR PENDAFTARAN

CALON PENGURUS KPMB YOGYAKARTA

2013 - 2014

1. NamaLengkap : ............................................................................................................

2. Tempat, TanggalLahir : ............................................................................................................

3. JenisKelamin : Laki-lakiPerempuan

4. Agama : ............................................................................................................

5. AlamatJogja : ............................................................................................................

6. AlamatBalikpapan : ............................................................................................................

7. Universitas&Jurusan : ............................................................................................................

8. AsalSMA : ............................................................................................................

9. No.Telp / HP / Pin BB : ............................................................................................................

10. Email/YM/FB/Twitter : ............................................................................................................

11. UkuranPDH : S / M / L / XL ket : L / P

12. Hobby : ............................................................................................................

DIVISI YANG DIPILIH

KesejahteraanAnggota

Pengembangan SDM

Minat&Bakat

HubunganMasyarakat

Sosial&Rohani Kesekretariatan&Wirausaha

ket :

Maksimalpilih (✓) 2 divisi,untukdipertimbangkanolehtimformatur

Melampirkan : CV, 1 lembarFoto 3x4 (color), dan1 lembarfoto copy KTM& KTP