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KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS LAMPUNGBADAN PELAKSANA KKN UNIVERSITAS LAMPUNG

Jl. Sumantri Brojonegoro No. 1 Gedung Meneng Bandar LampungTelp. (0721) 70424! "a# (0721) 70424

FORMULIR PENDAFTARAN MAHASISWA KKN TAHUN 2016

A. DATA PERIBADI

1. Nama $

%%%%%%%%%%%%%%%%%%%%%%%%%.2. N&M $

%%%%%%%%%%%%%%%%%%%%%%%%%.'. &rogram Studi $

%%%%%%%%%%%%%%%%%%%%%%%%%.4. aulta* $

%%%%%%%%%%%%%%%%%%%%%%%%%.

+. ,on*entra*i $

%%%%%%%%%%%%%%%%%%%%%%%%%.. Total S,S-&,/ $

%%%%%%%%%%%%%%%%%%%%%%%%%.7. Tempat Tanggal Lair $

%%%%%%%%%%%%%%%%%%%%%%%%%.. lamat 3omi*ili $

%%%%%%%%%%%%%%%%%%%%%%%%%.. Jeni* ,elamin $

%%%%%%%%%%%%%%%%%%%%%%%%%.10. 5o66 $

%%%%%%%%%%%%%%%%%%%%%%%%%.11. ,ealian ,u*u* $

%%%%%%%%%%%%%%%%%%%%%%%%%.12. Telpon 8uma $

%%%%%%%%%%%%%%%%%%%%%%%%%.1'. 5& $

%%%%%%%%%%%%%%%%%%%%%%%%%.14. Tempat tinggal *al $

%%%%%%%%%%%%%%%%%%%%%%%%%.1+. 9uran Baju $

%%%%%%%%%%%%%%%%%%%%%%%%%.B. DATA ORANG TUA

1. aa. Nama $

%%%%%%%%%%%%%%%%%%%%%%%%%.6. &eerjaan $

%%%%%%%%%%%%%%%%%%%%%%%%%.:. Telpon 8uma $

%%%%%%%%%%%%%%%%%%%%%%%%%.

d. 5p $

%%%%%%%%%%%%%%%%%%%%%%%%%.2. lamat ;rang Tua $

%%%%%%%%%%%%%%%%%%%%%%%%%.C. DATA ORANG YANG SEGERA DAPAT DIHUBUNGI

1. Nama $

%%%%%%%%%%%%%%%%%%%%%%%%%.2. lamat $

%%%%%%%%%%%%%%%%%%%%%%%%%.'. Telp-5& $

%%%%%%%%%%%%%%%%%%%%%%%%%.4. 5u6ungan Maa*i*

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3emiian data ini *aa 6uat dengan *e6enarna untu dipergunaan *e6agai*arat penda"taran :alon pe*erta ,,N Taun 201. pa6ila ada data ang *aa6uat ternata pal*u! maa *aa 6er*edia menerima *an*i *e6agimaname*tina.

Mengetaui! Bandar Lampung!201

&em6im6ing ademi =ang Mem6uat.........................

(..............................................)(................................................)N& $........................................N&M $.......................................

,etua Juru*an..................

(................................................)N& $........................................