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SURAT PERNYATAAN

KESEDIAAN MENJADI MAHASISWA

JALUR SNMPTN UNDANGAN 2013

Pada hari ini ............... tana!........ "#!an.......tah#n...... $an "%rtanda tanandi"a&ah ini '

Na(a' ..................................................................................................

T%()at* Tana! Lahir' ..................................................................................................

N+(+r Ind#, S%,+!ah' ..................................................................................................

N+(+r Ind#, Si-&a Na-i+na! '

..................................................................................................

N+(+r P%ndataran' ..................................................................................................

Uni/%r-ita- Pr+ra( St#di

' ..................................................................................................

M%n$ata,an d%nan -%-#n#hn$a "ah&a '

1. %r-%dia (%nadi (aha-i-&a dari #ni/%r-ita- ...................................Pr+ra( -t#di ........................................................................... a)a"i!adit%ri(a (%!a!#i a!#r SNMPTN Undanan 2013 Pi!ihan 1 #ni/%r-ita-4

2. M%ndatar,an diri )ada #ni/%r-ita- dan )r+ra( -t#di $an (%n$ata,an(%n%ri(a -a$a -%"aai (aha-i-&a 2013

3. Sa$a (%n$adari "ah&a a)a"i!a -a$a tida, (%na("i! ,%-%()atan ini*(a,a a,an (%n#rani ,%)%r5a$aan Uni/%r-ita- t%rhada) -%,+!ah dan"%ri()!i,a-i )ada "%r,#rann$a ,%-%()atan dan ata# tida, di"%ri,ann$a,%-%()atan )ada )r+ra( SNMPTN Undanan ata# -%%ni-n$a )adatah#n6tah#n "%ri,#tn$a.

7. S#rat )%rn$ataan ini di"#at dan ditanda tanani da!a( ,%adaan -adar dantan)a adan$a t%,anan dari )iha, (ana)#n.

8. %r-%dia (%n%ri(a -an,-i a)a)#n $an di"%ri,an )iha, -%,+!ah a)a"i!a(%!anar )%r$ataan $an t%!ah ,a(i "#at.

Yan (%n$ata,an*

Ja,arta*.................................2013

Yan "%rtan#n Ja&a" Yan (%("#at P%rn$ataan9ran T#a: Wa!i Si-&a

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SURAT PERNYATAAN

KESEDIAAN MENJADI MAHASISWA

JALUR PPK:TALENT S;9UTING 2013

Pada hari ini ............... tana!........ "#!an.......tah#n...... $an "%rtanda tanandi"a&ah ini '

Na(a' ..................................................................................................

T%()at* Tana! Lahir' ..................................................................................................

N+(+r Ind#, S%,+!ah' ..................................................................................................

N+(+r Ind#, Si-&a Na-i+na! '

..................................................................................................

N+(+r P%ndataran' ..................................................................................................

Uni/%r-ita- Pr+ra( St#di

' ..................................................................................................

M%n$ata,an d%nan -%-#n#hn$a "ah&a '

1. %r-%dia (%nadi,an Uni/%r-ita- Ind+n%-ia (%nadi Pi!ihan 1 Uni/%r-ita-da!a( )i!ihan SNMPTN Undanan 2013

2. %r-%dia (%nadi (aha-i-&a dari Uni/%r-ita- Ind+n%-ia Pr+ra(-t#di ........................................................................... a)a"i!a dit%ri(a(%!a!#i a!#r SNMPTN Undanan 2013 Pi!ihan 1 #ni/%r-ita-4:PPK: Ta!%nt

S5+#tin3. M%ndatar,an diri )ada #ni/%r-ita- dan )r+ra( -t#di $an (%n$ata,an

(%n%ri(a -a$a -%"aai (aha-i-&a 20137. Sa$a (%n$adari "ah&a a)a"i!a -a$a tida, (%na("i! ,%-%()atan ini*

(a,a a,an (%n#rani ,%)%r5a$aan Uni/%r-ita- t%rhada) -%,+!ah dan"%ri()!i,a-i )ada "%r,#rann$a ,%-%()atan dan ata# tida, di"%ri,ann$a,%-%()atan )ada )r+ra( SNMPTN Undanan ata# -%%ni-n$a )adatah#n6tah#n "%ri,#tn$a.

8. S#rat )%rn$ataan ini di"#at dan ditanda tanani da!a( ,%adaan -adar dantan)a adan$a t%,anan dari )iha, (ana)#n.

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Yan (%n$ata,an*

Ja,arta*.................................2013

Yan "%rtan#n Ja&a" Yan (%("#at P%rn$ataan9ran T#a: Wa!i Si-&a

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