Professional Documents
Culture Documents
SEKOLAH PASCASARJANA
Nama Lengkap
..........................................................................................................................
NIP./No.SK*)
..........................................................................................................................
Pangkat/Golongan
..........................................................................................................................
..........................................................................................................................
Jenis Kelamin**)
a. Laki-laki
b. Perempuan
Status Perkawinan**)
a. Kawin
b. Belum Kawin
..........................................................................................................................
Alamat Kantor
..........................................................................................................................
Alamat Asal
..........................................................................................................................
Telepon.....................................................
10
Alamat di Malang
..........................................................................................................................
Telepon.....................................................
11
12
13
14
15
a. Univ./Inst./ST
..........................................................................................................................
b. Fakultas
..........................................................................................................................
c. Jurusan/Program Studi
..........................................................................................................................
d. Tahun Lulus
..........................................................................................................................
e. I P Kumulatif
..........................................................................................................................
a. Univ./Inst./ST
..........................................................................................................................
b. Fakultas
..........................................................................................................................
c. Jurusan/Program Studi
..........................................................................................................................
d. Tahun Lulus
..........................................................................................................................
e. I P Kumulatif
..........................................................................................................................
Malang, ................................2012
Pendaftar,
......................................................
Tandatangan & Nama Terang
Berwarna
3x4
Berwarna
3x4
Keterangan:
a.
*) Bagi yang punya NIP./Bagi pegawai swasta
b.
**) Supaya dilingkari yang Benar dan diisi
Berwarna
3x4
Berwarna
3x4
Berwarna
3x4
PERNYATAAN KESEDIAAN
MEMATUHI PERATURAN YANG BERLAKU
Yang bertanda tangan dibawah ini, saya:
1. Nama
................................................................................................................
...............................................................................................................
3. Instansi
................................................................................................................
4. Jabatan
................................................................................................................
5. Strata Studi*
6. Program Studi*
Menyatakan bahwa saya bersedia mematuhi peraturan yang berlaku pada Program Pascasarjana
Universitas Islam Negeri Maulana Malik Ibrahim Malang. Apabila dikemudian hari saya tidak dapat
memenuhi kewajiban sebagaimana yang saya nyatakan, maka saya bersedia menanggung sanksi sesuai
dengan peraturan yang berlaku.
Malang,..................................................
Yang menyatakan,
Materai
6000
..............................................................
Nama Terang dan Tanda Tangan
Keterangan:
*) Lingkari yang benar
KEMENTERIAN AGAMA
SEKOLAH PASCASARJANA
Tempat/Tgl. Lahir
:
Tgl.
NIM
Program
Prodi
Bln.
Tahun
Pascasarjana
Malang, .................,....................2012
Foto Berwarna
3x4
Mahasiswa
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