4a. Biodata Ijazah S1
KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI
UNIVERSITAS JEMBER
FAKULTAS KESEHATAN MASYARAKAT
Foto
4x6
ditempel dulu
baru
difotocopy
BIODATA IJAZAH
SARJANA STRATA SATU ( S1 )
NOMOR IJAZAH : …………..…/ KM / S1 / 20.….
NOMOR SERI IJAZAH : ……………………......
1.
Nama
: ............................................................................................................. (sesuai dg ijazah SMU)
2.
Tempat, tanggal lahir
: .............................................................................................................
3.
NIM (lengkap)
: .............................................................................................................
4.
Jenis Kelamin / Agama
: ................................................................ / ...............................................................
5.
Status
: Kawin / Belum Kawin
6.
Alamat yang dihubungi
: ...................................................................................................................................
(sesuai dg ijazah SMU)
No. Telp............................................... No. HP.....................................................
7.
Terdaftar sebagai Mhs.
: September ..........................................................
8.
Lulus Ujian Skripsi
: ................................................................................
9.
Judul Skripsi
: ..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
10. Lama Studi
: ..................................................................................................................................................
11. IP :
12. Ketua Penguji
: ..................................................................................................................................................
Sekretaris
: ..................................................................................................................................................
Penguji I
: ..................................................................................................................................................
Penguji II
: ..................................................................................................................................................
13. Orang Tua / Wali
: ..................................................................................................................................................
Pekerjaan
: ..................................................................................................................................................
Alamat yang dihubungi
: ..................................................................................................................................................
No. Telp...............................................
14. Pendidikan
: Nama Sekolah
Tahun Lulus
SD
..........................................................................................
..................................
SMP
..........................................................................................
..................................
SMU
..........................................................................................
..................................
Jember,
Mengetahui :
Wakil Dekan I,
Dr. Farida Wahyu Ningtyias, M.Kes.
NIP. 19801009 200501 2 002
Foto
4X6
ditempel dulu
baru
difotocopy
yang membuat,
______________________________
NIM.
Catatan :
Biodata ijazah ini supaya diketik / di print dengan jelas sesuai ijazah SMU
Dikumpulkan dalam map semua rangkap 3, yaitu : biodata ijazah, transkirp, ijazah SMU, SLTP, SD
Foto hitam putih ukuran 4X6 (10 lbr) jas warna terang selain putih.
UNIVERSITAS JEMBER
FAKULTAS KESEHATAN MASYARAKAT
Foto
4x6
ditempel dulu
baru
difotocopy
BIODATA IJAZAH
SARJANA STRATA SATU ( S1 )
NOMOR IJAZAH : …………..…/ KM / S1 / 20.….
NOMOR SERI IJAZAH : ……………………......
1.
Nama
: ............................................................................................................. (sesuai dg ijazah SMU)
2.
Tempat, tanggal lahir
: .............................................................................................................
3.
NIM (lengkap)
: .............................................................................................................
4.
Jenis Kelamin / Agama
: ................................................................ / ...............................................................
5.
Status
: Kawin / Belum Kawin
6.
Alamat yang dihubungi
: ...................................................................................................................................
(sesuai dg ijazah SMU)
No. Telp............................................... No. HP.....................................................
7.
Terdaftar sebagai Mhs.
: September ..........................................................
8.
Lulus Ujian Skripsi
: ................................................................................
9.
Judul Skripsi
: ..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
10. Lama Studi
: ..................................................................................................................................................
11. IP :
12. Ketua Penguji
: ..................................................................................................................................................
Sekretaris
: ..................................................................................................................................................
Penguji I
: ..................................................................................................................................................
Penguji II
: ..................................................................................................................................................
13. Orang Tua / Wali
: ..................................................................................................................................................
Pekerjaan
: ..................................................................................................................................................
Alamat yang dihubungi
: ..................................................................................................................................................
No. Telp...............................................
14. Pendidikan
: Nama Sekolah
Tahun Lulus
SD
..........................................................................................
..................................
SMP
..........................................................................................
..................................
SMU
..........................................................................................
..................................
Jember,
Mengetahui :
Wakil Dekan I,
Dr. Farida Wahyu Ningtyias, M.Kes.
NIP. 19801009 200501 2 002
Foto
4X6
ditempel dulu
baru
difotocopy
yang membuat,
______________________________
NIM.
Catatan :
Biodata ijazah ini supaya diketik / di print dengan jelas sesuai ijazah SMU
Dikumpulkan dalam map semua rangkap 3, yaitu : biodata ijazah, transkirp, ijazah SMU, SLTP, SD
Foto hitam putih ukuran 4X6 (10 lbr) jas warna terang selain putih.