Formulir Pendaftaran PMB

Penerimaan Mahasiswa Baru

POLITEKNIK LPP YOGYAKARTA
FORMULIR PENDAFTARAN

Foto 4x6

ISILAH DENGAN HURUF KAPITAL
1. Program
2. Nama Lengkap
3. Jenis Kelamin
4. Tempat Lahir
Propinsi
Kabupaten/Kota
5. Alamat Rumah
Telp/Hp
Propinsi
Kabupaten/Kota
6. Nama Orang Tua
Pekerjaan
Alamat

7. Asal Sekolah
Propinsi
Kabupaten/Kota
Jurusan
8. Nilai Raport

Reguler
Karyawan
Beasiswa
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Agama
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: Pria/Wanita (coret yang tidak perlu)
: .............................................................. Tanggal Lahir : ..................................
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.............................................................. Kode Pos

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Kelas 3
Mata Pelajaran

smt 1

smt 2

Matematika
B. Indonesia

B. Inggris
9. Nilai UAN
10.Pilihan Prodi 1

:
:

,

D3 Teknik Mesin

D3 Teknik Kimia

D3 Budidaya Tanaman Perkebunan
11. Pilihan Prodi 2

D3 Akuntansi
D4 Budidaya Tanaman Perkebunan

:

D3 Teknik Mesin

D3 Teknik Kimia

D3 Budidaya Tanaman Perkebunan
No. Pendaftaran (diisi oleh petugas)

D3 Akuntansi
D4 Budidaya Tanaman Perkebunan
Yogyakarta,
Pendaftar

Nama & Paraf Petugas (.................)
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