Formulir Pendaftaran Papi 2015 Edit Fix

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................

2015 001

3...................................................................................................

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

TAHAP – TAHAP PELAKSANAAN1. Pendaftaran

a. Pendaftaran dibuka sejak tanggal 12 Oktober 2015 – 11 November 2015

b. Tempat pengumpulan formulir dan pembayaran biaya pendaftaran :HMP DIII JURUSAN GIZI POLTEKKES KEMENKES MALANGSenin – Jumat : 15.00 – 18.00 WIBCP : Izza 0857 777 37311

Robby 081 555 865 482biaya pendaftaran bisa di TRANSFER MELALUI REKENINGBANK MANDIRI A/N. NISHAR ZULMI 90000 1986 4967

2. Seleksi tulis, wawancara dan minat bakat dilaksanakan pada :Hari / Tanggal : Sabtu, 21 November 2015Waktu : 07.30 - selesaiTempat : Jurusan Gizi Poltekkes Kemenkes Malang

3. Grand Final dilaksanakan pada :Hari / Tanggal : Jumat, 27 November 2015Waktu : 18.30 – selesai

1. Laki laki / perempuan sehat jasmani dan rohani dan bebas dari penyalah gunaan NARKOBA

2. Merupakan Warga Negara Indonesia3. Usia 16-22 tahun dan belum menikah

Foto 4x6

KRITERIA PESERTA

PETUNJUK TEKNISPEMILIHAN PUTRA PUTRI GIZI KOTA MALANG 2015

Tercatat sebagai mahasiswa aktif semester 1-4 Jurusan Gizi di Universitas se-Malang Raya

4. IMT normal5. Berkepribadian dan berpenampilan menarik, berbakat dan kreatif 6. Berwawasan luas dan komunikatif7. Diutamakan mampu berkomunikasi bahasa inggris dengan baik

1. Fotocopy KTP dan KTM masing – masing 2 lembar2. Pas Foto 4x6 (2 lembar) 3. Foto berwarna terbaru (*)

a. Close Up ukuran 4R (1 lembar) b. Seluruh badan 4R (1 lembar)

4. Surat izin / rekomendasi dari Jurusan / Prodi 5. Mengisi formulir pendaftaran6. Seluruh berkas dimasukkan dalam map kertas warna biru (putra)

dan warna merah muda (putri)*dengan background foto bebas, memakai pakaian bebas, sopan dan rapi.

PERSYARATAN PENDAFTARAN

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................

2015 002

3...................................................................................................

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

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

Foto 4x6

2015 003

NO HP:.................................................................................

......................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

Foto 4x6

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

2015 004

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kg

Foto 4x6

2015 005

ASAL PERGURUAN TINGGI:.................................................................................

.................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

Foto 4x6

2015 006

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)

Foto 4x6

2015 007

JURUSAN / FAKULTAS: ................................................................................

......................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................

Foto 4x6

2015 008

NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................

Foto 4x6

2015 009

SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)

Foto 4x6

2015 010

TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................

2015 011

TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................

Foto 4x6

2015 012

NAMA ORANG TUA: ................................................................................

......................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

Foto 4x6

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

2015 013

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................

Foto 4x6

2015 014

ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

Foto 4x6

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2015 015

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)

Foto 4x6

2015 016

ALAMAT MALANG: ................................................................................

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

......................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

Foto 4x6

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

2015 017

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

Foto 4x6

2015 018

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARAN

Foto 4x6

PEMILIHAN PUTRA PUTRI GIZIKOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

2015 019

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

FORMULIR PENDAFTARANPEMILIHAN PUTRA PUTRI GIZI

KOTA MALANG 2015

NO PENDAFTARAN :

NAMA LENGKAP : ......................................................................................................NAMA PANGGILAN : ......................................................................................................JENIS KELAMIN : LAKI LAKI / PEREMPUAN (*)TEMPAT TANGGAL LAHIR : ......................................................................................................USIA : ............th, agama : ...............................................................NAMA ORANG TUA

: ......................................................................................................ALAMAT ASAL : ...................................................................................................... ...................................................................................................(**)ALAMAT MALANG

: ......................................................................................................

........................................................................................................NO HP

:.......................................................................................................

Foto 4x6

2015 020

TB/BB : ................... cm., .................. kgASAL PERGURUAN TINGGI

:..................................................................................................(**)JURUSAN / FAKULTAS

: ......................................................................................................SEMESTER : ......................................................................................................HOBBY : ......................................................................................................TALENTA : ......................................................................................................PRESTASI : 1. .................................................................................................

Tingkat ..................................................................................

2. .................................................................................................

Tingkat ..................................................................................3..............................................................................

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

Tingkat...................................................................................

(*) pilih salah satu(**) disertai fotocopy KTP dan KTM

Malang, .....................................................

(.....................................................................)

Foto 4x6