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PROGRAM MAGISTER (S2)ADMINISTRASI NEGARAFAKULTAS ILMU SOSIAL DAN ILMU POLITIK

UNIVERSITAS MALIKUSSALEHFORMULIR PENDAFTARAN MAHASISWA

(APPLICATION FOR GRADUATE ADMISSION)

BIODATA MAHASISWA (Personal Details)

Nama Lengkap :(Full Name)

Tempat/TglLahir :(Place/Date of Birth)

Jenis Kelamin : [ ]Laki-laki[ ]Perempuan(Gender) (Male) (Female)

Agama :(Religion)

Suku Bangsa :(Race)

Warga negara :(Nationality)

Status Perkawinan :(Marital Status)

No. Kartu (KTP) :(Identity Card No.)

No. Pasport :(Pasport No.)

Alamat :(Address)

No. Tel : ........................................................................................................................(Tel. No.)

No. Fak : ........................................................................................................................(Fax. No.)

HP : ........................................................................................................................(Mobile)

E-mail : ........................................................................................................................(E-mail)

ORANG YANG DAPAT DIHUBUNGI SAAT DARURAT / Person to be notified in case of emergency

Nama : ........................................................................................................................(Name)

Hubungan : ........................................................................................................................(Relationship)

Alamat : ........................................................................................................................(Address)

HP : ........................................................................................................................(Mobile)

* Catatan :Beri tandakan ( X )Note : Please tick ( X ) whichever applicable

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LATAR BELAKANG AKADEMIK (Academic Background)

Nama Sekolah dan Alamat(Name and Address of College)

Jurusan(Departement)

Tahun Masuk(Year of Entry)

Tanggal Ijazah(Date of Graduation)

Ijazah yang diperoleh(Degree Obtained)

PENDIDIKAN TAMBAHAN (Academic Additional)

Kursus/Pelatihan(Course/Trainning)

Tempat(Place)

Lamanya(Time)

Tahun(Year)

RIWAYAT PEKERJAAN/PENGALAMAN (Employment Details/Experience)

Nama Jabatan(Name of Positions)

Nama dan Alamat(Employer’s name and address)

Rentang Waktu(From - To)

Keterangan(Description)

KEMAMPUAN BAHASA dan TPA (Language and GMAT Proficiency)

Kemampuan(Proficiency)

Nama Lembaga/Ujian(Name of Examination/Test)

Nilai/Skor(Grade)

Tahun Lulus(Year Passed)

TOEFL

IELTS

TPA


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PUBLIKASI ILMIAH (Professional Publications)

Buku/Jurnal(Title of Book/Journal)

Tahun Diterbitkan(Year of Publication)

Nama dan Tempat Penerbitan(Name and Location of Publication)

BANTUAN KEUANGAN (Financial Support)

Sebutkan sumber bantuan keuangan anda(Please indicate your source of financial support)

Dibiayai penuh oleh Negara / Beasiswa(Fully sponsored by government)

Dibiayai penuh oleh Perusahaan / Yayasan(Fully sponsored by employer)

Biaya sendiri/keluarga(Supported by myself / my family)

Nama dan alamat penanggung jawab atau organisasi yang akan membayar biaya Anda(Name and address of person and organization paying your fees)

___________________________________________________________________________________

___________________________________________________________________________________


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REKOMENDASI AKADEMIK [dua (2) orang](Academic Referees) [two (2) people]

Pemberi rekomendasi akademik adalah mereka yang mengenali calon dari bidang akademik (contoh : Dekan, Dosen, Pimpinan) dan sebaiknya bukan kawan atau saudara sendiri.(The academic referees must comprise of those who know the applicant in terms of his/her academic performance [e.g. : Dean, Lecturer, Employer] and should not have any personal acquaintances or relatives)

1) Nama : ______________________________ 2) Nama : ______________________________(Name) (Name)

Alamat : ______________________________ Alamat : ______________________________(Address) (Address)

______________________________ ______________________________

______________________________ ______________________________

No. HP. : ______________________________ No. HP. : ______________________________(Mobile) (Mobile)

Jabatansaatini : _________________________ Jabatansaatini : __________________________(Official Postion) (Official Postion)

PERNYATAAN (Declaration)

Dengan ini saya nyatakan bahwa semua keterangan di atas dan dokumen yang saya berikan adalah benar dan lengkap. Universitas Malikussaleh Lhokseumawe berhak menolak permohonan ini sekiranya keterangan tersebut didapati palsu dan/atau tidak lengkap.

(I hereby certify that the above information and documents enclosed are true and complete. University of Malikussaleh Lhokseumawe reserves the right to reject this application if the information given is false and/or incomplete).

_________________________ __________________________TandatanganPemohon Tanggal(Applicant’s Signature) (Date)


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SURAT REKOMENDASI(Referee’s Report)

Surat rekomendasi ini hendaklah diisi oleh pemberi rekomendasi sendiri dan diberikan kepada pemohon untuk dihantar bersama dengan formulir permohonan.(This report must be sealed by the referees and forward the envelope to the applicant to be submitted together with the application form)

BAHAGIAN A : TENTANG CALON(Part A : The applicant)

Nama Calon : _____________________________________________________________(Name)

Program Magister : _____________________________________________________________(Programme of Studies)

Alamat : _____________________________________________________________(Address)

BAHAGIAN B : PEMBERI REKOMENDASI(Part B : To be Completed by the referee)

Nama : _____________________________________________________________(Name)

Jabatan Saat ini : _____________________________________________________________(Official Position)

Alamat : _____________________________________________________________(Address)

No. Tel : _____________________________________________________________(Tel. No.)

No. Fak : _____________________________________________________________(Fax. No.)

HP : _____________________________________________________________(Mobile)

E-mail : _____________________________________________________________(E-mail)

BAHAGIAN C : LAPORAN PEMBERI REKOMENDASI(Part C : Referee’s Report)

a) Berapa lamakah Anda mengenali Calon? ……………..Tahun(How long have you known the applicant? No. of years)

b) Bagaimana Anda mengenali Pemohon?(How do you know the applicant?)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c) Dalam kapasitas hubungan apa Anda mengenal Calon?(What is your relationship to the applicant?)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

d) Adakah Anda percaya Calon akan mampu untuk menyelesaikan pendidikannya?(Do you believe that the applicant is prepared for graduate?)[ ] Ya(Yes) [ ] Tidak(No)


e) Bagaimanakah Anda menilai Calon terhadap hal-hal sebagai berikut? (Tandakan)

(How do you rate the applicant on each of the following?) (Please tick

Cemerlang(Excellent)

AmatBaik(Very Good)

Baik(Good)

Sederhana(Average)

Lemah(Poor)

1) Kecakapan intelek(Intellectual ability)

2) Kematangan dan kestabilan emosi(Maturity and emotional )

3) Motivasi(Motivation)

4) Pengetahuan Umum(General Knowledge)

5) Inisiatif(Initiative)

6) Kerjasama(Ability to cooperate)

7) Tanggung jawab(Responsibility)

PEMBERI REKOMENDASI (Recommendation)

__________________________ ___________________________Tandatangan/Nama Jelas Tanggal

(Referee’s Signature) (Date)


SURAT REKOMENDASI(Referee’s Report)

Surat remendasi ini hendaklah diisi oleh pemberi rekomendasi sendiri dan diberikan kepada pemohon untuk dihantar bersama dengan formulir permohonan.(This report must be sealed by the referees and forward the envelope to the applicant to be submitted together with the application form)

BAHAGIAN A : TENTANG CALON(Part A : The applicant)

Nama Calon : _____________________________________________________________(Name)

Program Magister : _____________________________________________________________(Programme of Studies)

Alamat : _____________________________________________________________(Address)

BAHAGIAN B : PEMBERI REKOMENSASI(Part B : To be Completed by the referee)

Nama : _____________________________________________________________(Name)

JabatanSaat ini : _____________________________________________________________(Official Position)

Alamat : _____________________________________________________________(Address)

No. Tel : _____________________________________________________________(Tel. No.)

No. Fak : _____________________________________________________________(Fax. No.)

HP : _____________________________________________________________(Mobile)

E-mail : _____________________________________________________________(E-mail)

BAHAGIAN C : LAPORAN PEMBERI REKOMENDASI(Part C : Referee’s Report)

a) Berapa lamakah Anda mengenali Calon? ……………..Tahun(How long have you known the applicant? No. of years)

b) Bagaimana Anda mengenali Pemohon?(How do you know the applicant?)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c) Dalam kapasitas hubungan apa Anda mengenal Calon?(What is your relationship to the applicant?)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

d) Adakah Anda percaya Calon akan mampu untuk menyelesaikan pendidikannya?(Do you believe that the applicant is prepared for graduate?)[ ] Ya(Yes) [ ] Tidak(No)


e) Bagaimanakah Anda menilai Calon terhadap hal-hal sebagai berikut? (Tandakan)

(How do you rate the applicant on each of the following?) (Please tick

Cemerlang(Excellent)

Amat Baik(Very Good)

Baik(Good)

Sederhana(Average)

Lemah(Poor)

8) Kecakapan intelek(Intellectual ability)

9) Kematangan dan kestabilanemosi(Maturity and emotional )

10) Motivasi(Motivation)

11) Pengetahuan Umum(General Knowledge)

12) Inisiatif(Initiative)

13) Kerjasama(Ability to cooperate)

14) Tanggung jawab(Responsibility)

PEMBERI REKOMENDASI (Recommendation)

__________________________ ___________________________Tanda tangan/Nama Jelas Tanggal

(Referee’s Signature) (Date)


PERSYARATAN PESERTA

Nama Calon : ..................................................................................................................................(Name)

No. Test : ..................................................................................................................................(Test No.)

Angkatan : ..................................................................................................................................

Kelas : Khusus / A / B(Class)

No PERSYARATAN LENGKAP BELUM LENGKAP KETERANGAN

1 Foto Copy Ijazah (legalisir) PTN (S-1) PTS (S-1) Luar Negeri (S-1)

…………………….…………………….…………………….

…………………….…………………….…………………….

…………………….…………………….…………………….

2 Foto Copy Transkrip Nilai (legalisir) PTN (S-1) PTS (S-1) Luar Negeri (S-1)

…………………….…………………….…………………….

…………………….…………………….…………………….

…………………….…………………….…………………….

3 SK Rektor/Ketua Yayasan ……………………. ……………………. …………………….

4 Pas Photo Warna Ukuran 4 x 6 cm = 2 lembar 3 x 4 cm = 6 lembar 2 x 2,5 cm = 4 lembar

…………………….…………………….…………………….

…………………….…………………….…………………….

…………………….…………………….…………………….

5 FORMULIR PENDAFTARAN ……………………. ……………………. …………………….

6 2 BUAH SURAT REKOMENDASI ……………………. ……………………. …………………….

7 NILAI TPA TOEFL

…………………….…………………….

…………………….…………………….

…………………….…………………….

8 SURAT KESEHATAN ……………………. ……………………. …………………….

Lhokseumawe, ………………………………2015

Panitia Penerimaan Mahasiswa Baru,

…………………………………………………………..

NIP.


formulir pendaftaran 2015 indra.docx

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