Colleger register

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Information about Colleger register
Education

Published on April 24, 2014

Author: Lisateamproject

Source: slideshare.net

Description

Colleger register

FORMULIR PERMOHONAN PENDAFTARAN PENERIMAAN MAHASISWA BARU JALUR PMDP UNIVERSITAS PGRI TAHUN AJARAN 20.... /20.... Kepada Yth. Direktur Universitas PGRI di- JAKARTA Foto 4x6 (ditempel disini) Yang bertandatangan di bawah ini, saya : 1. N a m a Lengkap : …………………………………………………………………………………………………… 2. Jurusan : ………………………………………………………………………………………………….. 3. Asal Sekolah : ………………………………………………………………………………………………….. 4. Alamat Rumah : ………………………………………………………………………………………………….. 5. No Tilp./HP : …………………………………………………………………………………………………… Dengan ini mengajukan permohonan untuk mengikuti seleksi penerimaan mahasiswa melalui program Penelusuran Minat dan Prestasi (PMDP) Politeknik Kesehatan Depkes Semarang T.A. 20.…/20.. dengan pilihan : 1

Program Studi : ……D.III Kesehatan Lingkungan …………………………………………..(lihat daftar jurusan/ prodi) 61 Diisi kode Program Studi REKAPITULASI NILAI RAPOR : Jurusan IPA N o Mata Pelajaran NILAI Rata-rata Kelas X Kelas XI Kelas XII Smt I Smt II Smt I Smt II Smt I 1 Bhs.Indonesia 2 Bhs. Inggris 3 Matematika 4 Fisika 5 Kimia 6 Biologi Rata-rata 2

REKAPITULASI PRESTASI : No NAMA KEGIATAN PRESTASI TINGKAT 1 2 3 4 5 Keterangan : 1. Nama kegiatan : diisi nama kegiatan yang diikuti 2. Prestasi : diisi prestasi yang diperoleh pada kegiatan tersebut 3. Tingkat : pada tingkatan apa kegiatan tersebut dilaksanakan ( SMU, Kecamatan, Kabupaten/Kota, Propinsi, Nasional, dll). CHECK LIST KELENGKAPAN PERSYARATAN 1 Bukti Transaksi Pembayaran Pendaftaran 2 Pasphoto hitam putih terbaru ukuran 4X6 cm (2 lembar) 3 Photo Copy rapor Semester I-V yang sudah dilegalisir 4 Surat Keterangan Sehat dari Dokter Pemerintah (BB, TB, Keterangan Tidak Buta Warna) Mengetahui : Orangtua/Wali, Semarang, Yang Mengajukan Permohonan, 3

____________________________ ____________________________ Mengetahui Kepala Sekolah ………………….. (……………………………………………….) CEK LIST PENDAFTARAN PMDP KODE PILIHAN : NAMA : …………………………………………………………………………… ASAL SEKOLAH : …………………………………………………………………………… NO TELP/HP : …………………………………………………………………………… JURUSAN : IPA / IPS KELENGKAPAN : NO URAIAN KELENGKAPAN ADA TIDAK ADA 1. SURAT PERMOHONAN PENDAFTARAN (form.1) 2. REKAPITULASI NILAI RAPOR (Form 2) 3. FOTO 4X6 2 LEMBAR (1 lembar ditempel di form.1) 4. FOTOKOPY RAPOR DILEGALISIR 5. SLIP/BUKTI SETOR BIAYA PENDAFTARAN 6. SURAT KETERANGAN DOKTER (BB/TB) 7. SURAT KETERANGAN TIDAK BUTA WARNA 8. ........................................................................................ KETERANGAN : JAKARTA, ……………………… PEMERIKSA ………………………………………….. ………………………………………….. (…………………………….) 4

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