BASTEK GROUP BASMEN TEKNOLOGI GROUP UNIVERSITAS TEKNOLOGI YOGYAKARTASekretariat : Jl Ringroad Utara, Jombor, Yogyakarta Telp : 085643291096, 085291856313

FORMULIR PENDAFTARAN ARISAN LAPTOP(Diisi menggunakan huruf KAPITAL) A. DATA UMUM 1. Nama Lengkap 2. Nomor Mahasiswa 3. Fakultas / Jurusan 4. Perguruan Tinggi 5. Alamat Asal 6. Alamat Tinggal 7. Agama 8. Tempat, Tanggal Lahir 9. Alamat e-mail / HP B. DATA KELUARGA 1. Nama Ayah / Ibu 2. Nama Wali 3. Alamat Orang Tua 4. 5. 6. 7. 8.

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................................................................................................................... ................................................................................................................... ................................................................................................................... ................................................................................................................... .................................................................................................................. ................................................................................................................... : ................................................................................................................... ................................................................................................................... : ............................................ Golongan Darah : .................................. : ................................................................................................................... : ............................................ Jenis Kelamin : ..................................

: ................................................................................................................... : ................................................................................................................... : ................................................................................................................... ................................................................................................................... Alamat Wali : ................................................................................................................... ................................................................................................................... Pekerjaan Orang Tua : Ayah : ................................... Ibu : ......................................... Wali : .............................................................................................. Jumlah Saudara Kandung: ................................................................................................................... Jumlah Saudara Tiri : ................................................................................................................... Anda Anak ke : ...................................................................................................................

Pas Foto 3x4

Pas Foto 3x4

Yogyakarta, PEMOHON

2012

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Catatan: 1. Surat ini sewaktu-waktu dapat dialihkan kepada Pimpinan Perguruan Tinggi untuk diproses secara Hukum. 2. Formulir dapat diperbanyak sesuai kebutuhan. 3. Dengan mengisi Formulir ini berarti anda menyetujui sarat dan ketentuan yang berlaku.