HIMPUNAN MAHASISWA PENCINTA ALAM
BAHTERA BUANA
POLITEKNIK NEGERI SRIWIJAYA
Jln. Srijaya Negara Bukit Besar Telp. 353414 Fax. 353918Palembang 30139, Email : himpala_bahtera_buana@yahoo.com
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FORMULIR PENDAFTARAN
Nama:...............................................................................................................Tempat,Tanggal Lahir:......................................................................................................../19..Asal Organisasi:...............................................................................................................Alamat Organisasi:................................................................................................................................................................................................................................Kategori: Lead Umum Putra Lead Umum PutriJunior PutraContact Person: ..............................................................................................................Photo3 x 4............................2009
Hormat Saya,Peserta
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