Formulir Pendaftaran Ldkm Hmti 2017 - Copy.docx

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FORMULIR PENDAFTARAN LATIHAN DASAR KEPEMIMPINAN MAHASISWA 2017-2018 NAMA

:……………………………………………..

NIM

:……………………………………………..

PROGRAM STUDI

:……………………………………………..

ANGKATAN

:……………………………………………..

TTL

:……………………………………………..

JENIS KELAMIN

:……………………………………………..

ALAMAT

:……………………………………………..

NO. TELP

:……………………………………………..

PEKERJAAN

:……………………………………………..

NAMA WALI

:……………………………………………..

ALAMAT

:……………………………………………..

NO. TELP

:……………………………………………..

PEKERJAAN

:…………………………………………….. Mengetahui ……,……….2017

Mahasiswa

Orang Tua/Wali

……………

……………

BUKTI PEMBAYARAN Nama NIM / Prodi Senilai Digunakan

:…………………………………………………….. :…………………………………………………….. : Rp. 280.000,00 ( Dua Ratus Delapan Puluh Ribu Rupiah) : Pembayaran Latihan Dasar Kepemimpinan Mahasiswa Teknik Industri Universitas Muhammadiyah Gresik 2017-2018 …………,……………… 2017 Penerima

………………..

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