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Transcript of file · Web viewApakah ada anggota keluarga yang pernah menerima Beasiswa ? ........
BIODATA CALON PESERTA LAZIS PLN P3B
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 : ...................................................................................................
Kabupaten : ...................................................................................................
Propinsi : ...................................................................................................
Telepon yang mudah dihubungi : ..................................................................................................
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 : ...................................................................................................
Kabupaten : ...................................................................................................
Propinsi : ...................................................................................................
Kode pos : ...................................................................................................
Telepon yang mudah dihubungi : ..................................................................................................
(milik pribadi / milik saudara / milik tetangga * 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 ................ Saudara ( Wajib diisi )
Apakah ada anggota keluarga yang pernah menerima Beasiswa ? .........................................................
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 tanggungannya : ................................................................................................................
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 PRESTASIAkademik / Sekolah
No. Bidang Perlombaan Peringkat / Rangking
1
2
3
4
5
6
7
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
Nama Peserta : ...................................................................................................Kegiatan pasca lulus SMA : ...................................................................................................Tahun masuk kuliah : ...................................................................................................Tujuan dan harapan mengikuti program : .....................................................................................Universitas / Fakultas / Jurusan yang dituju : ...............................................................................Pilihan 1 ( wajib diisi ) : ...................................................................................................Tarbiyah Jurusan : ...................................................................................................Sains Jurusan : ...................................................................................................Kelebihan diri : ................................................................................................... Kelemahan diri : ................................................................................................... Cita – cita1 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 ( Sekarang-kurangnya 2 Halaman Folio )
..................................... , 2015
( ............................................................. )
Ket * : coret yang tidak perlu
