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DAFTAR RIWAYAT HIDUP
Insformasi DiriNama Lengkap : ........................................................................................Nama Panggilan : ........................................................................................NIM : ........................................................................................Jenis Kelamin :Laki-laki / Perermpuan*Tempat/Tgl. Lahir : ........................................................................................Kewarganegaraan : ........................................................................................Tinggi/Berat Badan : Tinggi:………cm / berat: ……… kgAgama : ........................................................................................Suku : ........................................................................................Alamat asal : ........................................................................................
........................................................................................Alamat Sekarang : ........................................................................................
........................................................................................Alat transportasi ke kampus :………………………………………………………..Jalur Masuk Perguruan Tinggi : ........................................................................................No. Hp : ........................................................................................E-mail : ........................................................................................Facebook : ……………………………………………………......Status dalam Keluarga : ........................................................................................Anak Ke- : ........................................................................................Jumlah Saudara : ........................................................................................Bahasa Sehari-hari : ........................................................................................Penyakit yang Pernah Diderita : ........................................................................................Golongan Darah : A / B / O /AB*
Informasi Pendidikan Asal Sekolah : ........................................................................................Tahun Lulus : ........................................................................................Nilai Ujian Nasional : ........................................................................................Riwayat Pendidikan : ........................................................................................
........................................................................................ ........................................................................................ ........................................................................................
Riwayat Beasiswa : ........................................................................................ ........................................................................................ ........................................................................................ ........................................................................................
Informasi Orang Tua / WaliNama Orang Tua
Ayah : ........................................................................................Ibu : ........................................................................................
Alamat Orang Tua : ........................................................................................
*coret yang tidak perluDivisi Penelitian_Litbang_HMPF FKIP UNTAN
Pendidikan Terakhir Orang TuaAyah : ........................................................................................Ibu : ........................................................................................
Pekerjaan Orang TuaAyah : ........................................................................................Ibu : ........................................................................................
Penghasilan Orang tua per BulanAyah : ........................................................................................Ibu : ........................................................................................
No Hp Orang Tua : ........................................................................................Nama Wali : ........................................................................................Alamat Wali : ........................................................................................Pendidikan Terakhir Wali : ........................................................................................Pekerjaan Wali : ........................................................................................Penghasilan Wali per Bulan : ........................................................................................No Hp Wali : ........................................................................................
Informasi Minat dan BakatHobi : ........................................................................................Cita-cita : ........................................................................................
Alasan : ........................................................................................ Catatan Prestasi : ........................................................................................
........................................................................................
........................................................................................Minat : ........................................................................................
Alasan : ........................................................................................Bakat : ........................................................................................
Alasan : ........................................................................................
Foto 3 x 4
Pontianak, ………Agustus 2014
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*coret yang tidak perluDivisi Penelitian_Litbang_HMPF FKIP UNTAN