FORMULIR PENDAFTARAN PROGRAM DIPLOMA TIGA

KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

UNIVERSITAS PENDIDIKAN INDONESIA
Jl. Dr. Setiabudhi No, 229 Bandung 40154 Tlp. (022) 2013163 - 2013164 Fax (022) 2013651
Homepage : http://www.up.edu – E-mail Info@upi.edu

FORMULIR PENDAFTARAN PROGRAM DIPLOMA TIGA (D-3)
GELOMBANG 2 TAHUN 2017

DATA IDENTITAS DIRI
No. Seleksi
Nama Lengkap
Jenis Kelamin
Tempat/Tgl.Lahir
Agama
Warga Negara
Sts. Kawin
Golongan Darah
Pekerjaan
Jml. Adik
Jml. Kakak

Alamat Rumah

: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
:
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................

RT
: ......................................................................
RW
: ......................................................................
Kelurahan

: ......................................................................
Kecamatan
: ......................................................................
Kota
: ......................................................................
Provinsi
: ......................................................................
Kode pos
: ......................................................................
Email
: .......................................................................
Penanggungjawab Biaya: ......................................................................
No.HP Pendaftar
: .......................................................................
PENDIDIKAN
SD
Status
Thn.Lulus
SLTP
Status

Thn.Lulus
SLTA
Status
Thn.Lulus
Asal SLTA

: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................

DATA KELUARGA
Nama Orang Tua Ayah
Pekerjaan

Pendidikan
Alamat
Kabupaten
Penghasilan
Nama Orang Tua Ibu
Pekerjaan
Pendidikan
Alamat
Kabupaten
Penghasilan

: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................

: .......................................................................
: .......................................................................
: .......................................................................

DATA AKADEMIK
Nomor Induk Siswa Nasional
: .............................................
Nomor Pokok Sekolah Nasional
: .............................................
Prodi D-3 yang Dipilih : .......................................................................

Bandung,
Pendaftar,

Agustus 2017

Photo

.............................................