BIODATA

No. Kamar: ______________________________________No. KTP: ______________________________________Nama: ______________________________________Tempat/Tanggal Lahir: ______________________________________Alamat Sesuai Tanda Pengenal: ______________________________________ ______________________________________Agama: ______________________________________Suku: ______________________________________No. Telp: ______________________________________Universitas: ______________________________________Fakultas/Jurusan: ______________________________________

Nama Orangtua Ayah: ______________________________________ Ibu: ______________________________________Alamat: ______________________________________ ______________________________________No. Telp Ayah: ______________________________________ Ibu: ______________________________________

Nama Wali: ______________________________________Alamat: ______________________________________ ______________________________________No. Telp: ______________________________________

3x4

*lampiran fotokopi KTP dan KTM untuk keperluan RT/RW setempat