Formulir Pendaftaran UM-PN (Ok)

FORMULIR PENDAFTARAN

JALUR UJIAN MASUK POLITEKNIK NEGERI (UM-PN)

POLITEKNIK NEGERI TANAH LAUT

Data Diri

Nama Lengkap : .................................................................................................

Siswa Akselerasi * : Ya Tidak

Jenis Kelamin : .................................................................................................

Agama : .................................................................................................

Tempat Lahir : .................................................................................................

Tanggal Lahir : .................................................................................................

Alamat Rumah : .................................................................................................

Provinsi : .................................................................................................

Kota/Kab : .................................................................................................

Alamat Email : .................................................................................................

Telepon Rumah : .................................................................................................

Telepon Pribadi : .................................................................................................

Sekolah : .................................................................................................

Jurusan : .................................................................................................

Tahun Lulus : .................................................................................................

Data Rapor

Semester Peringkat Jumlah

Siswa

Nilai Rata-

rata Seluruh

Pelajaran

Nilai

Matematika Bahasa

Indonesia

Bahasa

Inggris

1

2

3

4

5

*) Khusus untuk siswa akselerasi diisi hanya sampai semester 3

Data Prestasi Ekstrakurikuler

Nama Lomba,

Kejuaraan, dll Skala

Jenis

(Olah raga, seni,

olimpiade, dll)

Juara Tahun

Data Keluarga

Nama Ayah : .................................................................................................

Status Ayah : .................................................................................................

Hubungan Ayah : .................................................................................................

Pendidikan Ayah : .................................................................................................

Pekerjaan Ayah : .................................................................................................

Pendapatan Ayah : .................................................................................................

Nama Ibu : .................................................................................................

Status Ibu : .................................................................................................

Hubungan Ibu : .................................................................................................

Pendidikan Ibu : .................................................................................................

Pekerjaan Ibu : .................................................................................................

Pendapatan Ibu : .................................................................................................

Nomer Telp Orang Tua/Wali : .....................................................................................

Jumlah Tanggungan : .....................................................................................

Jumlah Tabungan : .....................................................................................

Pilihan Politeknik

Pilihan 1 : Politeknik Negeri Tanah Laut

Prodi : Teknik Informatika / Teknologi Industri Pertanian / Mesin Otomotif (Pilih salah satu)





Bidik Misi (diisi jika Anda adalah calon pendaftar Beasiswa Bidik Misi)

KAP Bidik Misi : .....................................................................................

PIN Bidik Misi : .....................................................................................

Mengetahui,

Kepala Sekolah

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

................,............................2015

Tertanda,

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

Formulir Pendaftaran UM-PN (Ok)

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