formulir pengajuan beasiswa.doc

FORMULIR PENGAJUAN BEASISWAUNIVERSITAS BINA DARMA

NAMA : _____________________________________________________________

NIM : _____________________________________________________________

TEMPAT & TGL LAHIR : _____________________________________________________________

FAKULTAS : _____________________________________________________________

PROG. STUDI : _____________________________________________________________

JENIS KELAMIN : _____________________________________________________________

ALAMAT : _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

NO. TELP/HP : _____________________________________________________________

DATA ORANG TUA

NAMA : _____________________________________________________________

ALAMAT : _____________________________________________________________

_____________________________________________________________

NO. TELP/HP : _____________________________________________________________

PEKERJAAN : _____________________________________________________________

PENGHASILAN/BULAN : _____________________________________________________________

JML TANGGUNGAN : _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

DATA LAMPIRAN

Fotocopy KTM

Fotocopy KHS

Fotocopy Rekening Listrik Terakhir

Fotocopy PBB

Fotocopy Buku Rekening Tabungan

Fotocopy Kartu Keluarga

Surat Keterangan Penghasilan Orang Tua

Surat Keterangan Kurang Mampu

Surat Permohonan Pengajuan Beasiswa.

Mengetahui, Mengetahui, Palembang,

Ka. Prog. Studi, Kepala Kemahasiswaan Mahasiswa

Foto 3x4

NB : SEMUA BERKAS DIFOTOCOPY RANGKAP 3 DAN DIMASUKAN DALAM MAP KERTAS KAMBING WARNA HIJAU