BUKU INDUK MAHASISWA

Nama Mahasiswa : ............................................................................NIP: ............................................................................Program Studi: ............................................................................Motto Hidup: ............................................................................ ............................................................................

A. KETERANGAN PRIBADI1. Nama Panggilan: ...........................................................................................................2. Jenis Kelamin: ...........................................................................................................3. Tempat Tanggal Lahir: ...........................................................................................................4. Agama: ...........................................................................................................5. Kewarganegaraan: ...........................................................................................................6. Status: ...........................................................................................................B. KETERANGAN TEMPAT TINGGAL 7. Alamat : ........................................................................................................... ........................................................................................................... 8. Nomer Telepon: ........................................................................................................... 9. Alamat Email: ...........................................................................................................

C. KETERANGAN KESEHATAN 10. Berat badan: ........................................................................................................... 11. Tinggi badan: ........................................................................................................... 12. Golongan Darah: ...........................................................................................................

D. KETERANGAN PENDIDIKAN 13. SDa. Nama sekolah: ..........................................................................................................b. Tahun Lulus: .......................................................................................................... 14. SLTPa. Nama sekolah: .........................................................................................................b. Tahun Lulus: .........................................................................................................

15. SMUa. Nama sekolah: .........................................................................................................b. Tahun Lulus: .........................................................................................................

E. STATUS PERKAWINAN 16. Suami: ......................................................................................................... 17. Tempat tanggal lahir: ......................................................................................................... 18. Pekerjaan: ......................................................................................................... 19. Jumlah anak: .........................................................................................................F. SUSUNAN KELUARGANOOrang tuaAyahIbu

1Nama

2Tempat tanggal lahir

3Kewarganegaraan

4Pendidikan

5Pekerjaan

6Penghasilan/bulan/tahun

7Alamat

8Nomer Telp/HP

NOSEMESTERIP

1I

2II

3III

4IV

5V

6VI