formulir dlm.doc

KOMISI PEMILIHAN RAYAPresiden dan Wakil Presiden BEM serta Anggota DLM KBMF

Universitas Jenderal SoedirmanSekertariat Jl. dr. Soeparno Kampus Karangwangkal telp/fax (0281) 642840 Purwokerto 53122

Purwokerto 53122

FORMULIR PENDAFTARAN

CALON ANGGOTA DLM KBMF UNSOED

PERIODE 201 6 -201 6

I. BIODATA DIRI

Nama Lengkap :________________________________________________

Nama Panggilan : ________________________________________________

Jenis Kelamin : ________________________________________________

Tempat Tanggal Lahir : ________________________________________________

NIM : ________________________________________________

Fakultas/Departemen : ________________________________________________

Agama : ________________________________________________

No. Hp : ________________________________________________

Email dan facebook : ________________________________________________

Blog/Website : ________________________________________________

Anak ke-, dari - ..saudara : ________________________________________________

Asal SMA : ________________________________________________

Asal Daerah : ________________________________________________

Mottto Hidup : ________________________________________________

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Motivasi :________________________________________________

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Purwokerto,.............................2015

Calon Anggota DLM

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NIM.

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