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Tanggal Pengisian : ................................................................................

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

N I M : ................................................................................

Fakultas/ Jurusan : ................................................................................

T. Tgl Lahir : ................................................................................

T. Tinggal Sekarang : ................................................................................

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

Status : ................................................................................

Anak Ke - : …………………….. Dari ……………………….

No Hp : ................................................................................

Moto Hidup : ................................................................................

Hobi : ................................................................................

Warna yang Disukai : ................................................................................

Warna yang tidak Disukai : ................................................................................

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

Pekerjaan : ................................................................................

Umur : ................................................................................

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

Pekerjaan : ................................................................................

Umur : ................................................................................

T. Tinggal Ortu Sekarang : ................................................................................

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