DAFTAR RIWAYAT HIDUP

Insformasi DiriNama Lengkap : ........................................................................................Nama Panggilan : ........................................................................................NIM : ........................................................................................Jenis Kelamin :Laki-laki / Perermpuan*Tempat/Tgl. Lahir : ........................................................................................Kewarganegaraan : ........................................................................................Tinggi/Berat Badan : Tinggi:………cm / berat: ……… kgAgama : ........................................................................................Suku : ........................................................................................Alamat asal : ........................................................................................

........................................................................................Alamat Sekarang : ........................................................................................

........................................................................................Alat transportasi ke kampus :………………………………………………………..Jalur Masuk Perguruan Tinggi : ........................................................................................No. Hp : ........................................................................................E-mail : ........................................................................................Facebook : ……………………………………………………......Status dalam Keluarga : ........................................................................................Anak Ke- : ........................................................................................Jumlah Saudara : ........................................................................................Bahasa Sehari-hari : ........................................................................................Penyakit yang Pernah Diderita : ........................................................................................Golongan Darah : A / B / O /AB*

Informasi Pendidikan Asal Sekolah : ........................................................................................Tahun Lulus : ........................................................................................Nilai Ujian Nasional : ........................................................................................Riwayat Pendidikan : ........................................................................................

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

Riwayat Beasiswa : ........................................................................................ ........................................................................................ ........................................................................................ ........................................................................................

Informasi Orang Tua / WaliNama Orang Tua

Ayah : ........................................................................................Ibu : ........................................................................................

Alamat Orang Tua : ........................................................................................

*coret yang tidak perluDivisi Penelitian_Litbang_HMPF FKIP UNTAN

Pendidikan Terakhir Orang TuaAyah : ........................................................................................Ibu : ........................................................................................

Pekerjaan Orang TuaAyah : ........................................................................................Ibu : ........................................................................................

Penghasilan Orang tua per BulanAyah : ........................................................................................Ibu : ........................................................................................

No Hp Orang Tua : ........................................................................................Nama Wali : ........................................................................................Alamat Wali : ........................................................................................Pendidikan Terakhir Wali : ........................................................................................Pekerjaan Wali : ........................................................................................Penghasilan Wali per Bulan : ........................................................................................No Hp Wali : ........................................................................................

Informasi Minat dan BakatHobi : ........................................................................................Cita-cita : ........................................................................................

Alasan : ........................................................................................ Catatan Prestasi : ........................................................................................

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

........................................................................................Minat : ........................................................................................

Alasan : ........................................................................................Bakat : ........................................................................................

Alasan : ........................................................................................

Foto 3 x 4

Pontianak, ………Agustus 2014

___________________________

*coret yang tidak perluDivisi Penelitian_Litbang_HMPF FKIP UNTAN