Formulir Beres 27.docx

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FORMULIR PENDAFTARAN

BEASISWA PRESTASI ANGKATAN XXVII

Pas Foto Berwarna 3x4

1. DATA PRIBADI Nama Peserta

:

…..............................................................................................L / P

Tempat/Tanggal Lahir

:

…........................................................................ Umur : ……………...............

Alamat Lengkap (Sekarang)

:

…......................................................................................................................... …......................................................................................................................... …......................................................................................................................... ……………..........................................................Provinsi: ………………….….

Telp/Hp(Whatsapp)

:

….........................................................................................................................

Email

:

……………………………...…………………………………………….….………...

Instagram

:

………………………………………………………

Agama

:

…………….……….................................................

2. RIWAYAT PENDIDIKAN NAMA SEKOLAH / TINGKAT

TAHUN JURUSAN

PERGURUAN TINGGI

DARI

SAMPAI

IPK /

Kota/

NILAI

Kab

SD SMP SMA / K Perguruan Tinggi

Dompet Dhuafa Waspada Main Office : Jl. Kapten Muslim, Komp. Kapten Muslim Busines Point, Blok E, No. 17 Sei Sikambing, Medan.

Provinsi

3. DATA AKADEMIK Nama Universitas

:

….........................................................................................................................

Fakultas

:

………………………………………….................................................................

Jurusan

:

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

Semester

:

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

4. RIWAYAT KURSUS / TRAINING / SEMINAR No

Nama Kegiatan

Penyelenggara

Periode Waktu

5. PENGALAMAN Berwirausaha No

Jenis Usaha

Tahun s/d s/d s/d

6. MOTIVASI Mengapa anda mendaftar beasiswa ini?

Formulir ini diisi dengan sebenar-benarnya …...............................................

(…..............................................)

Dompet Dhuafa Waspada Main Office : Jl. Kapten Muslim, Komp. Kapten Muslim Busines Point, Blok E, No. 17 Sei Sikambing, Medan.

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