Folmulir Calon BEM Farmasi

FORMULIR PENDAFTARAN CALON KETUA BEM FARMASI 2011/2012

 

Nama                                  :  ............................................................................................

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

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

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

Nim                                      :  ............................................................................................

Angkatan / Kelas              :  ............................................................................................

Pengalaman Organisasi    :           ............................................................................................

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

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

IPK                                       :  ............................................................................................

Harap melampirkan :

1. Fotocopy KTP asli
2. Fotocopy IP terakhir (IPK)

3. Foto 4x6 sebanyak 2 lembar, 3x4 sebanyak 2 lembar
4. Surat Aktif Kuliah.

..................................................... 2012

	Materai 6000

 

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