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SEKSI MAHASISWA IKATAN AHLI GEOLOGI INDONESIA

SEKOLAH TINGGI TEKNOLOGI NASIONAL

(SM IAGI STTNAS)

Sekertariat : Gedung A Lantai 1 Kampus STTNAS Yogyakarta

Jalan Babarsari, Caturtunggal Depok, Sleman, D.I Yogyakarta

Kode Pos 55281, Telp : 0899 1715 747, E-mail : [email protected]

FORMULIR PENDAFTARAN

Curriculum Vitae

Nama Lengkap : .....................................................

NIM / Angkatan : ................................./...................

Pas foto

3 X 4

(Foto Resmi dan Rapi)

IPK terakhir : .....................................................

Tempat, Tanggal Lahir : .....................................................

Alamat : .....................................................

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

Kode Pos : .....................................................

Jenis Kelamin : .....................................................

Agama : .....................................................

Status pernikahan : .....................................................

Telephone/ hp : .....................................................

E-Mail : .....................................................

Divisi / Departement yang dipilih di SM-IAGI STTNAS : ........................................

(Pilih salah satu)

1) KEILMUAN

2) PSDM (Pengembangan Sumberdaya Mahasiswa)

3) SOSMAS (Sosial Masyarakat)

4) INFOKOM (Informasi dan Komunikasi)

Orang tua :

Ayah : ....................................................................

Umur : ....................................................................

Pekerjaan : ....................................................................

Alamat : .................................................................... ....................................................................

Ibu : ....................................................................

Umur : ....................................................................

Pekerjaan : ....................................................................

Alamat : .................................................................... ....................................................................

Riwayat Pendidikan :

SD : ...............................................

Tahun ....... - ........

SMP / Sederajat : ...............................................

Tahun ....... - ........

SMA / Sederajat : ...............................................

Tahun ....... - ........

Sekolah Tinggi Teknologi Nasional (STTNAS) Yogyakarta

Tahun ....... - Sekarang

Pengalaman Organisasi :

Tahun ....... ........: ...................................................................................................

Apa motivasi kamu, dan seberapa besar niat serta komitment kamu untuk menjadi Pengurus SM-IAGI STTNAS Yogyakarta ?

ESSAY KEILMUAN

Tema Potensi Unconventional Energi di Indonesia

(Minimal 2 lembar, boleh di ketik atau di tulis tangan, tanpa gambar) ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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