form permohonan pengajuan beasiswa
TRANSCRIPT
KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGIUNIVERSITAS BRAWIJAYA
FAKULTAS ILMU ADMINISTRASIJl. MT. Haryono 163, Malang 65145, Indonesia
Telp. : +62-341-553737, 568914, 558226 Fax : +62-341-558227 http://fia.ub.ac.id E-mail: [email protected]
PERMOHONAN PENGAJUAN BEASISWA TAHUN 20......) :
1. PPA 3. SUPERSEMAR2. BBM 4. LAIN-LAIN..........................................
1. Nama Lengkap : .....................................................................................................................2. NIM : .....................................................................................................................3. Fakultas / Program Studi : Ilmu Administrasi / ......................................................................................4. Tempat / Tanggal Lahir : ……………………………….. / ....................................................................5. Alamat Asal (wajib diisi lengkap) : .....................................................................................................................6. No. telp. Asal (wajib diisi lengkap) : ( 0……….. ) ................................................................................................7. Alamat di Malang (wajib diisi lengkap) : .....................................................................................................................8. Telpon di Malang / HP. (wajib diisi lengkap) : ……………………………….. / ................................................................... 9. Duduk Pada Semester : .....................................................................................................................10. IPK / SKS : ............................................... / ..................................................................11. Jenis Kelamin : Laki-Laki / Perempuan *)
12. Agama : Islam / Kristen / Katolik / Hindu / Budha *)
13. Data Orang Tua :a. Nama Ayah : ..................................................................................................................... Alamat : .....................................................................................................................
Pendidikan : SD / SMP / SMA / D 3 / S1 / S2 / S3 *)
Pekerjaan (spesifik) : .....................................................................................................................Jumlah Penghasilan / bulan : .....................................................................................................................
b. Nama Ibu : .....................................................................................................................Alamat : .....................................................................................................................Pendidikan : SD / SMP / SMA / D 3 / S1 / S2 / S3 *)
Pekerjaan (spesifik) : .....................................................................................................................Jumlah Penghasilan / bulan : .....................................................................................................................
14. Jumlah tanggungan orangtua yang masih sekolaha. SD : .....................................................................................................................b. SMP : .....................................................................................................................c. SMA : .....................................................................................................................d. Perguruan Tinggi : .....................................................................................................................
15. Organisasi kemahasiswaan yang diikuti ( dilampiri foto copy Struktur Organisasi yang disahkan oleh Ketua Lembaga )a. .....................................................................................; jabatan .............................................................................................b. .....................................................................................; jabatan .............................................................................................c. .....................................................................................; jabatan .............................................................................................
16. Prestasi Non Akademik yang pernah diraih ( dilampiri foto copy sertifikat)a. .....................................................................................; sebagai ............................................................................................b. .....................................................................................; sebagai ............................................................................................c. .....................................................................................; sebagai ............................................................................................
17. Sebutkan beasiswa apabila pernah / tahun : ................................................................. / .........................................................18. Alamat email dan blog : ..............................................................................................................................................................
Dengan ini saya mengajukan Beasiswa ........................................................................... tahun 2015 dan dengan ini pula menyatakan bahwa saya tidak sedang menerima beasiswa dari sumber lain.
Malang, ………. - ………… - 20…...Mengetahui Yang MengajukanBagian Kemahasiswaan
…………………………………………NIM. …………………………………..
(.......................................................)
*) Coret yang tidak perlu) Lingkari Yang Dipilih