FORMULIR PENDAFTARAN FORM DATA DIRI A 1. Data Pribadi

FORMULIR PENDAFTARAN
" "FORM DATA DIRI "A "
"Data Pribadi " " "
"Nama Lengkap ": "O "
" " "N "
" " "K "
" " "I "
" " " "
" " "N "
" " "U "
" " "R "
" " " "
" " "I "
" " "N "
" " "D "
" " "R "
" " "I "
" " "A "
" " "N "
" " "T "
" " "O "
" " " "
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" " " "
"Tempat, Tanggal Lahir": "B "
" " "A "
" " "N "
" " "Y "
" " "U "
" " "W "
" " "A "
" " "N "
" " "G "
" " "I "
" " " "
" " " "
" " ", "
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" " " "
" " "1 "
" " "1 "
" " "- "
" " "F "
" " "E "
" " "B "
" " "R "
" " "U "
" " "A "
" " "R "
" " "I "
" " " "
" " "- "
" " "1 "
" " "9 "
" " "9 "
" " "2 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Agama ": "I "
" " "S "
" " "L "
" " "A "
" " "M "
" " " "
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" " " "
"Jenis Kelamin ": " "
" " "Pria "
" " " "
" " "Wanita "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
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" " " "
"Status ": " "
" " "Menikah "
" " " "
" " "Belum Menikah "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
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" " " "
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" " " "
" " " "
"No KTP (NIK) ": "3 "
" " "5 "
" " "1 "
" " "0 "
" " "0 "
" " "6 "
" " "1 "
" " "1 "
" " "0 "
" " "2 "
" " "9 "
" " "2 "
" " "0 "
" " "0 "
" " "0 "
" " "5 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Alamat (sesuai dg ": "D "
"KTP) " "U "
" " "S "
" " "U "
" " "N "
" " " "
" " "C "
" " "E "
" " "M "
" " "E "
" " "T "
" " "U "
" " "K "
" " " "
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" " " "
"RT/RW ": "0 "
" " "0 "
" " "3 "
" " "/ "
" " "0 "
" " "0 "
" " "2 "
" " " "
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" " " "
" " " "
"Desa ": "C "
" " "L "
" " "U "
" " "R "
" " "I "
" " "N "
" " "G "
" " " "
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" " " "
"Kecamatan ": "C "
" " "L "
" " "U "
" " "R "
" " "I "
" " "N "
" " "G "
" " " "
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" " " "
"Kota / Kabupaten ": "B "
" " "A "
" " "N "
" " "Y "
" " "U "
" " "W "
" " "A "
" " "N "
" " "G "
" " "I "
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" " " "
"Provinsi ": "J "
" " "A "
" " "W "
" " "A "
" " " "
" " "T "
" " "I "
" " "M "
" " "U "
" " "R "
" " " "
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" " " "
"Kode Pos ": "6 "
" " "8 "
" " "4 "
" " "8 "
" " "2 "
" " " "
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" " " "
"Status Tempat Tinggal": " "
" " "Kost "
" " " "
" " "Sewa "
" " " "
" " "Ikut Saudara "
" " " "
" " "Orang Tua "
" " " "
"Alamat Tempat Tinggal": "D "
" " "U "
" " "S "
" " "U "
" " "N "
" " " "
" " "C "
" " "E "
" " "M "
" " "E "
" " "T "
" " "U "
" " "K "
" " " "
" " "R "
" " "T "
" " "/ "
" " "R "
" " "W "
" " " "
" " "0 "
" " "3 "
" " "/ "
" " "0 "
" " "2 "
" " " "
" " "D "
" " "E "
" " "S "
" " "A "
" " " "
" " "C "
" " "L "
" " "U "
" " "R "
" " "I "
" " "N "
" " "G "
" " " "
" " " "
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" " " "
" " " "
" " " "
" " " "
" " " "
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" " " "
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" " " "
"Provinsi ": "J "
" " "A "
" " "W "
" " "A "
" " " "
" " "T "
" " "I "
" " "M "
" " "U "
" " "R "
" " " "
" " " "
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" " " "
" " " "
" " " "
" " "A "
" " "N "
" " "Y "
" " "U "
" " "W "
" " "A "
" " "N "
" " "G "
" " "I "
" " " "
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" " " "
"Kode Pos ": "6 "
" " "8 "
" " "4 "
" " "8 "
" " "2 "
" " " "
" " " "
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" " " "
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"No. Telepon Rumah ": "- "
" " " "
" " " "
" " " "
" " "- "
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" " " "
"No. Seluler (HP) ": "0 "
" " "8 "
" " "7 "
" " "8 "
" " "- "
" " "5 "
" " "7 "
" " "8 "
" " "9 "
" " "2 "
" " "5 "
" " "9 "
" " "9 "
" " " "
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" " " "
"Email ": "O "
" " "N "
" " "K "
" " "I "
" " "N "
" " "U "
" " "R "
" " ". "
" " "I "
" " "N "
" " "D "
" " "R "
" " "I "
" " "A "
" " "N "
" " "T "
" " " @ "
" " "G "
" " "M "
" " "A "
" " "I "
" " "L "
" " ". "
" " "C "
" " "O "
" " "M "
" " " "
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"Facebook " "O "
" " "N "
" " "K "
" " "I "
" " " "
" " "N "
" " "U "
" " "R "
" " " "
" " "I "
" " "N "
" " "D "
" " "R "
" " "I "
" " "A "
" " "N "
" " "T "
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"Twitter ": "- "
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"Hobi ": "O "
" " "L "
" " "A "
" " "H "
" " " "
" " "R "
" " "A "
" " "G "
" " "A "
" " " "
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" " " "
"Data Keluarga " " "
"Nama Ayah ": "E "
" " "N "
" " "D "
" " "R "
" " "I "
" " " "
" " "M "
" " "A "
" " "R "
" " "W "
" " "O "
" " "T "
" " "O "
" " " "
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" " " "
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" " " "
"Pekerjaan ": "P "
" " "E "
" " "T "
" " "A "
" " "N "
" " "I "
" " " "
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"Penghasilan / bulan ": "R "
" " "P "
" " ". "
" " "1 "
" " ". "
" " "0 "
" " "0 "
" " "0 "
" " ". "
" " "0 "
" " "0 "
" " "0 "
" " " "
" " " "
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" " " "
"No. Telepon Rumah/ No": "0 "
"Seluler " "8 "
" " "5 "
" " "2 "
" " "3 "
" " "0 "
" " "5 "
" " "0 "
" " "3 "
" " "8 "
" " "6 "
" " "4 "
" " " "
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"Nama Ibu ": "A "
" " "L "
" " "M "
" " ". "
" " "E "
" " "N "
" " "D "
" " "A "
" " "H "
" " " "
" " "N "
" " "U "
" " "R "
" " "Y "
" " "A "
" " "T "
" " "I "
" " " "
" " " "
" " " "
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" " " "
"Pekerjaan ": "- "
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"Penghasilan / bulan ": "- "
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"No. Telepon Rumah/ No": "- "
"Seluler " " "
" " " "
" " " "
" " "- "
" " " "
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" " " "
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" " " "
"Alamat ": "D "
" " "U "
" " "S "
" " "U "
" " "N "
" " " "
" " "C "
" " "E "
" " "M "
" " "E "
" " "T "
" " "U "
" " "K "
" " " "
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" " " "
" " " "
" " " "
" " " "
"RT/RW ": "0 "
" " "0 "
" " "3 "
" " "/ "
" " "0 "
" " "0 "
" " "2 "
" " " "
" " " "
" " " "
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" " " "
"Kel/Desa ": "C "
" " "L "
" " "U "
" " "R "
" " "I "
" " "N "
" " "G "
" " " "
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" " " "
"Kecamatan ": "C "
" " "L "
" " "U "
" " "R "
" " "I "
" " "N "
" " "G "
" " " "
" " " "
" " " "
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" " " "
" " " "
" " " "
" " "A "
" " "N "
" " "Y "
" " "U "
" " "W "
" " "A "
" " "N "
" " "G "
" " "I "
" " " "
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" " " "
" " " "
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" " " "
"Provinsi ": "J "
" " "A "
" " "W "
" " "A "
" " " "
" " "T "
" " "I "
" " "M "
" " "U "
" " "R "
" " " "
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" " " "
"Kode Pos ": "6 "
" " "8 "
" " "4 "
" " "8 "
" " "2 "
" " " "
" " " "
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"Jumlah anak kandung ": " "
"yang menjadi " "1 "
"tanggungan orang tua:" " "
"(belum menikah dan " "2 "
"belum bekerja) " " "
" " "3 "
" " " "
" " "4-dst "
" " " "

" "FORM KETERANGAN INSTITUSI "B "
"Nama Institusi ": "U "
" " "N "
" " "I "
" " "V "
" " "E "
" " "R "
" " "S "
" " "I "
" " "T "
" " "A "
" " "S "
" " " "
" " "J "
" " "E "
" " "M "
" " "B "
" " "E "
" " "R "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Alamat Institusi ": "J "
" " "L "
" " ". "
" " "K "
" " "A "
" " "L "
" " "I "
" " "M "
" " "A "
" " "N "
" " "T "
" " "A "
" " "N "
" " " "
" " "N "
" " "O "
" " ": "
" " "3 "
" " "7 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " "K "
" " "A "
" " "M "
" " "P "
" " "U "
" " "S "
" " " "
" " "T "
" " "E "
" " "G "
" " "A "
" " "L "
" " " "
" " "B "
" " "O "
" " "T "
" " "O "
" " " "
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" " " "
" " " "
"Kota / Kabupaten ": "J "
" " "E "
" " "M "
" " "B "
" " "E "
" " "R "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
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"Provinsi ": " "
" " " "
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" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Kode Pos ": "6 "
" " "8 "
" " "1 "
" " "2 "
" " "1 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"No. Telepon ": "0 "
" " "3 "
" " "3 "
" " "1 "
" " "- "
" " "3 "
" " "3 "
" " "0 "
" " "2 "
" " "2 "
" " "4 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"No. Fax ": "0 "
" " "3 "
" " "3 "
" " "1 "
" " "- "
" " "3 "
" " "3 "
" " "7 "
" " "4 "
" " "2 "
" " "2 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Nomor Induk ": "1 "
"Mahasiswa " "1 "
" " "1 "
" " "9 "
" " "0 "
" " "3 "
" " "1 "
" " "0 "
" " "2 "
" " "0 "
" " "2 "
" " "1 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Tahun Masuk ": "2 "
" " "0 "
" " "1 "
" " "1 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Nama Fakultas ": "T "
" " "E "
" " "K "
" " "N "
" " "I "
" " "K "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Nama Jurusan ": "E "
" " "L "
" " "E "
" " "K "
" " "T "
" " "R "
" " "O "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Nama Prodi ": "D "
" " "I "
" " "P "
" " "L "
" " "O "
" " "M "
" " "A "
" " " "
" " "3 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"IP Komulatif ": "3 "
" " ". "
" " "3 "
" " "7 "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "

*) Institusi bisa diganti sekolah / universitas

" "FORM PENDIDIKAN "C "
" " " "
"JENJANG "INSTITUSI "TAHUN MASUK "TAHUN KELUAR "NILAI AKHIR "
"(SD / MI) * "SDN 3 CLURING"1998 "2004 "38.93 "
"(SMP / MTS) * "SMPN 1 "2004 "2007 "25.13 "
" "CLURING " " " "
"(SMK / SMA / MA) "SMA 1 CLURING"2007 "2010 "51.60 "
"* " " " " "
"(D3 /S1 / S2 / "UNIV. JEMBER "2011 "- "- "
"S3) * " " " " "

* ) Lingkari Sesuai Pilihan

" " "DATA ORGANISASI "D "
" " " " "
"NO. "NAMA ORGANISASI "JABATAN "TINGKAT "TAHUN MASUK "TAHUN "
" " " " " "KELUAR "
" "Kontribusi Terbesar: "
" " "
"2 "ROBOTIKA "ANGGOTA "FAKULTAS "2012 "- "
" " "
"3 "- "- "- "- "- "
" " "

" " "FORM PRESTASI "E "
" " " " "
" "NAMA LOMBA"TINGKAT "PERINGKAT"PESERTA "JABATAN "TEMPAT "TAHUN "
"2 "FKIP CUP "JEMBER "- "- "TIM "JEMBER "2013 "
" " " " " " " " "
" " " " " " " " "
" " " " "

" " "FORM PENGALAMAN KERJA "F "
" " " " "
"NO. "NAMA "BIDANG "JABATAN "PIMPINAN "TAHUN "TAHUN "
" "INSTANSI " " " "MASUK "KELUAR "
" "Deskripsi Kerja: "
"2 " " " " " " "
"3 " " " " " " "
" " " " " " " "
" " "FORM PELATIHAN / SEMINAR / WORKSHOP "G "
" " " " "
"NO. "KATEGORI "JUDUL "PENYELENGGARA "SKALA "TAHUN "
" "Nilai Manfaat: "
"2 " " " " " "
" "Nilai Manfaat: "
"3 " " " " " "
" "Nilai Manfaat: "

" "KEMAMPUAN BAHASA "H "
" " " "
"BAHASA "BICARA "MENGERTI "MENULIS "TIPE "SKOR "TANGGAL "
" " " " "TEST " " "
" " " " " " " "
" " " " " " " "
" " " "
" "FORM REKOMENDASI "I "
" " " "
"NAMA REKOMENDASI "JABATAN "EMAIL "NO. TELEPON "
" " " " "
" " " " "
" " " " "

" "DATA TAMBAHAN "J "
"Apakah saudara pernah menerima beasiswa: " "
" " "
"Ya " "
" " "
"Tidak " "
" " "
" " "
"Kalau Ya, dari: " "
"NAMA BEASISWA "INSTANSI PEMBERI "PERIODE BEASISWA "NILAI BEASISWA "
" "BEASISWA " " "
" " " " "
" " " " "
" " " " "

" "KESEHATAN "L "
" " " "

Jawablah masing - masing pertanyaan!

"Apakah Anda secara periodik ": " "
"memeriksa kesehatan? " "Ya "
" " " "
" " "Tidak "
" " " "
"Tahun berapa Anda terakhir menjalani": "2000-2014 "
"pemeriksaan kesehataan? " " "
"Apakah anda pernah dirawat di rumah ": " "
"sakit? " "Ya "
" " " "
" " "Tidak "
" " " "
"(berkaitan dengan No. 3) Jika iya ": " "
"jelaskan untuk penyakit apa saja " " "
"anda dirawat? " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Apakah Anda saat ini sedang ": " "
"menjalani pengobatan? Jika iya " " "
"jelaskan pengobatan apa? " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
"Apakah anda mempunyai riwayat ": " "
"penyakit? Jika iya jelaskan " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "
" " " "

" "PENGEMBANGAN POTENSI DAERAH *) "K "
" " " "

Jawablah masing - masing pertanyaan dengan jelas sesuai dengan potensi di
daerah anda!

1. Seperti apakah daerah tempat asal saya?
" "

2. Potensi dan sumber daya apa yang ada di daerah saya tetapi belum
teroptimalisasi?
" "

3. Langkah apa yang saya lakukan untuk mengembangkan daerah saya terutama
untuk menciptakan system pembangunan berkelanjutan dari daerah saya?
" "

4. Tuangkan segala cita-cita, harapan, keinginan anda setelah lulus program
beasiswa sobat bumi dalam 1 paragraf pendek pada kolom di bawah ini !

" "

*) "daerah" bisa diganti sekolah / universitas

" "ALASAN PENGAJUAN BEASISWA DAN LAIN-LAIN "M "
" " " "

1. Apa motivasi anda untuk melamar Beasiswa Sobat Bumi?
" "

2. Tindakan apa yang pernah Anda lakukan yang memberikan manfaat bagi orang
lain dan paling berkesan bagi Anda? Mengapa Anda melakukan itu?
" "

3. Sebutkan 3 (tiga) hal yang menjadi kekuatan karakter diri Anda dan 3
(tiga) hal yang menjadi kelemahan karakter diri Anda !
" "

4. Apa rencana dan strategi Anda sebagai upaya penyelamatan Bumi?
" "

5. Jelaskan mengapa kami harus memilih Anda menjadi Penerima Beasiswa Sobat
Bumi?
" "

6. Sebutkan minat Anda dalam bidang apa saja dan bakat apa saja yang Anda
miliki?
" "

" "DOKUMEN PENDUKUNG "N "
" " " "

Dokumen Pendukung yang harus dilengkapi:
1. Pas Foto ukuran 4 x 6
2. Copy KTM /
3. KTP
4. Kartu Keluarga
5. Copy transkrip dilegalisir
6. Copy Kartu Rencana Study
7. Surat Rekomendasi Tokoh
8. Surat Rekomendasi Kampus
9. Surat Pernyataan Penerima Beasiswa Sobat Bumi

Lampiran 2

SURAT PERNYATAAN PENERIMA

BEASISWA SOBAT BUMI PERTAMINA FOUNDATION

Yang bertanda tangan dibawah ini:
Nama :
Tempat dan Tanggal Lahir :
Status :
Nomor Induk Pelajar / Mahasiswa :
Nomor KTP :
Fakultas/Jurusan :
Sekolah / Perguruan Tinggi :
Alamat :
RT ………. / RW ………. No. ………. Kelurahan
Kecamatan….......…………….. Kota
Kode Pos
Nomor Tlp/HP :

Dengan ini menyatakan bahwa setelah saya memahami, maka saya memutuskan
untuk memenuhi ketentuan-ketentuan sebagaimana dimaksud dalam Panduan
Program Beasiswa Sobat Bumi Pertamina Foundation serta mengabdi kepada
kepentingan Bangsa Indonesia.

Sebagai konsekuensinya saya bersedia dihentikan/penundaan untuk menerima
beasiswa serta tidak akan melakukan tuntutan dan/atau gugatan dalam bentuk
apapun kepada Pertamina Foundation, apabila hal-hal sebagai berikut:
- Lulus atau dikeluarkan dari sekolah / perguruan tinggi
- Meninggal dunia
- Menikah
- Melakukan pelanggaran dan ketentuan yang berlaku di sekolah /
perguruan tinggi
- Mengundurkan diri sebagai penerima beasiswa Sobat Bumi Pertamina
Foundation
- Indeks prestasi tidak memenuhi syarat
- Menerima beasiswa dari lembaga lain dalam waktu yang bersamaan
- Tidak melaporkan hasil belajar kepada Pertamina Foundation
- Tidak ikut dalam kegiatan yang diwajibkan oleh Pertamina
Foundation
- Terlibat tindakan melanggar hukum / penyalahgunaan dan atau
pengedaran obat-obat terlarang
- Memalsukan informasi yang dimuat dalam formulir aplikasi dan
dokumen-dokumen sehubungan dengan pembuatan dan pelaksanaan
perjanjian beasiswa ini

Demikian surat pernyataan ini dibuat secara sadar dan tanpa paksaan dalam
bentuk apa pun dari pihak manapun untuk dipergunakan sebagaimana mestinya.

--------------------------, -----------------------------

Tanda Tangan

------------------------------------------

Lampiran 3

SURAT REKOMENDASI – TOKOH MASYARAKAT

Yang bertanda tangan di bawah ini:
Nama :
NIP :
Pangkat/Gol :
Jabatan :
Instansi :
Alamat Lembaga
Tlp :
Faks :
E-mail :

Memberikan rekomendasi kepada:
Nama :
Fakultas :
Jurusan :
Perguruan Tinggi :
Alamat :

Isi rekomendasi meliputi:
1. Berapa lama saudara telah mengenal pelamar

2. Dalam kapasitas apa saudara berinteraksi dengan pelamar

3. Berikan informasi tentang aktivitas dan prestasi pelamar yang perlu
diperhatikan

4. Berikan alasan saudara merekomendasikan pelamar

5. Berikan penilaian saudara atas berapa aspek yang penilaian dengan
memberi tanda silang kepada pilihan saudara

" "Sangat Baik"Baik "Cukup "Kurang "
"Kepemimpinan " " " " "
"Keterlibatan dalam komunitas " " " " "
"Kepercayaan diri " " " " "
"Kedewasaan " " " " "
"Kemampuan beradaptasi " " " " "
"Potensi untuk berkembang " " " " "
"Potensi untuk menjadi pemimpin " " " " "
"Idealisme terhadap kebenaran " " " " "
"Kemampuan akademik " " " " "

--------------------------, -----------------------------

------------------------------------------

Lampiran 4

KOP UNIV
SURAT REKOMENDASI PERGURUAN TINGGI
No. xx/xx/xxxx

Yang bertanda tangan dibawah ini adalah
"Nama ":"………………………………………………………………………………. "
"NIP ":"………………………………………………………………………………. "
"Pangkat/Golong":"………………………………………………………………………………. "
"an " " "
"Jabatan ":"………………………………………………………………………………. "
"Instansi ":"………………………………………………………………………………. "

Menyatakan bahwa mahasiswa dibawah ini:
"Nama ":"……………………………………………………………………………………………. "
"NIM ":"……………………………………………………………………………………………. "
"Jurusa":"……………………………………………………………………………………………. "
"n " " "
"Prodi ":"……………………………………………………………………………………………. "

Adalah benar:
1. Sedang tidak menerima beasiswa dari pihak lain dan tidak ada ikatan
dinas

2. Berkelakuan baik

3. Tidak pernah melanggar kode etik akademik Perguran Tinggi

4. Mahasiswa aktif Fakultas …………………….. pada semester genap tahun ajaran
……………………..

Dengan Pertimbangan di atas kami merekomendasikan untuk dapat mengikuti
seleksi Beasiswa Sobat Bumi periode ………………………………
Demikian surat ini di buat keterangan ini dibuat agar dapat dipergunakan
sebagaimana mestinya.

" "…………………… , ………………………… "
" " "
" "Wakil Dekan Bidang Akademik "
" " "
" " "
" "NAMA LENGKAP "
" " "
" " "
" "NIP. ………………………………….. "

-----------------------
Meterai
6.000

FORMULIR PENDAFTARAN FORM DATA DIRI A 1. Data Pribadi

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