Formulir Pendaftaran Prosus Inten 2016-2017.Docx...

Lembaga Konsultasi, Persiapan, dan Pemantapan UM –PTN Jalan Aceh No. 62 Bandung Jalan Reog II No. 5 Buah Batu, Bandung Jalan Abdul Rahman Saleh No. 75 Bandung Jalan Gandapura No.33 Bandung Jalan Gatot Subroto,Komp Pusdik Bekang TNI Cimahi Jalan Guntur Sari Wetan No. 15

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FORMULIR PENDAFTARAN Nama Lengkap

: ______________________ ____________________________________________ ______________________________________ ________________

Tempat, Tgl. Lahir

: ________________________ ___________________________________________ ____________________________________ _________________

Alamat Lengkap

: ________________________ ___________________________________________ ____________________________________ _________________  _______________  ________ ________________ ________________Kode _______Kode Pos __________ __________________ ___________ ___

Alamat Email

: ______________________ _____________________________________________ ______________________________________ _______________

Nomor Telepon Siswa : ________________  _______________________ _______________ ________________ ________________ ________________ _____________ _____ Sekolah

: ________________________ ____________________________________________ ____________________________________ ________________

Kelas

: [2 IPA] [1 IPA] [3 SMP] [2 IPS] [ALUMNI IPS] *

Nama Orang tua

: [Bapak] __________________ ________________________[Ibu] ______[Ibu] _____________________ _________________________ ____

Pekerjaan Pekerj aan Orang tua

: [Bapak] __________________ ________________________[Ibu] ______[Ibu] ____________________ _________________________ _____

Nomor Telepon Ortu

: [Bapak] __________________ ________________________[Ibu] ______[Ibu] _____________________ _________________________ ____

Nomor Telp.Rum Telp.Rumah ah

: __________________ _________________________________________ __________________________________________ ___________________

Biaya Operasi Operasional onal

: __________________ ___________________________________________ __________________________________________ _________________

Biaya Pendid Pendidikan ikan

:____________________________[Pro :_______________ _____________[Program] gram] __________________ ________________________ ______

Biaya Matriku Matrikulasi lasi

: ________________________ __________________________________________________ ____________________________________ __________

Batas Pelunas Pelunasan an

: _______________________ ____________________________ _____

[ACC] _________________________

Dengan ini, saya mendaftarkan diri sebagai Calon Peserta Program Khusus Belajar dan Latihan UM-PTN Prosus INTEN Bandung. Saya bermina berminatt masuk Jurusan / Fakultas : _____________________ ____________________________ _______ [

] **

Bandung,_________________________ Mengetahui, Orang Tua Calon Peserta

 _______________________  ____________ ___________

Pas Foto Ukuran 3 X 4 cm

Tanda tangan Calon Peserta

________________________ _____________ ___________