form pendaftaran staf hima d3kkim 2012-2013
TRANSCRIPT
FORMULIR PENDAFTARAN STAFF HIMA D3KKIM FTI-ITS 2012-2013
Nama Lengkap : ...................................................................................................Nama Panggilan : ...................................................................................................NRP : ...................................................................................................Tempat tanggal lahir : ...................................................................................................Agama : ...................................................................................................Alamat asal : ...................................................................................................Alamat Surabaya : ...................................................................................................No. Hp : ...................................................................................................E-mail : ...................................................................................................IPK : ...................................................................................................Motto Hidup : .............................................................................................................................................................................................................................................
Bakat dan keterampilan (boleh lebih dari 1)a) organisasib) menulis (karya tulis/jurnalistik)c) desaind) olah raga
e) kewirausahaanf) senig) dll, sebutkan .......................
.............................................
Proker HIMA D3KKIM yang anda ketahui1. ...........................................................................2. ...........................................................................3. ...........................................................................4. ...........................................................................5. ...........................................................................
Transportasi sehari-hari : ......................................................Bahasa sehari-hari : ......................................................
Pilihan Bidang sesuai dengan minat & bakat anda :
Bidang Akademik dan Kesejahteraan Mahasiswa
Bidang Pengembangan Sumber Daya Mahasiswa
Bidang Keprofesian dan Keilmiahan
Bidang Dalam Negeri
Bidang Hubungan Masyarakat
Bidang Kewirausahaan
*angka 1 prioritas tertinggi, angka 6 prioritas terendah
Alasan memilih bidang tersebut pada prioritas utama :..............................................................................................................................................................................................................................................................................................................................................................................................................................
Motivasi masuk ke HIMA D3KKIM FTI-ITS :..............................................................................................................................................................................................................................................................................................................................................................................................................................
Deskripsi diri : ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Komitmen ketika menjadi staf HIMA D3KKIM FTI-ITS 2012-2013 :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Pas Photo
4 x 6
Surabaya, Juli 2012
Pendaftar
(....................................)
Formulir bisadiperbanyak sendiri
(difotokopy)
SURAT PERNYATAAN
Yang bertanda tangan di bawah ini:
Nama lengkap : NRP :
menyatakan bahwa saya sanggup menjalankan semua proker dan mentaati semua aturan HIMA D3KKIM FTI-ITS 2012-2013.
Demikian surat pernyataan ini saya buat. Atas perhatiannya saya mengucapkan terima kasih.
Surabaya , Juli 2012
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