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FORMULIR PENDAFTARAN

CALON ANGGOTA BARU UKM MARITIME CHALLENGE

No. urut

:……… ……………………………… …………………(diisi oleh panitia)

Nama lengkap

:…………………………………….. ………………………………………..

Nama panggilan

:……………………………………………………………… ………………..

Jurusan / Fakultas

:……………………………….. …………………………………………… …

NRP

:…………………….…………………………………………… ……………..

Tempat/tanggal lahir

:………………………………………………………………………………..

Alamat sekarang

:……………………………….. ……………………………………………..
……………………………….. ……………………………………………..

No Tlp / HP

:……………………………….. …………………………………………… …

Alamat Asal

:……………………………….. …………………………………………… ..
……………………………….. …………………………………………… …

No Telepon

:……………………………….. …………………………………………… …

Hobi

:……………………………….. …………………………………………… …

Motivasi masuk
Maritime Challenge

:……………………………….. …………………………………………… .
:……………………………….. ……………………………………………..
:……………………………….. ……………………………………………..
Surabaya, ......…………..…….2012

3x4

(………………………………….…………)
NRP…………………………
Keterangan:

Formulir diisi dengan huruf kapital

Formulir dapat digandakan

Formulir diserahkan sendiri(tidak boleh diwakilkan)

Lampiran 2 lembar foto copy KTM/ bukti pendaftaran mahasiswa ITS

Mengumpulkan foto ukuran 3 x 4 dan 4 x 6. Masing-masing 2 lembar

Segala informasi mengenai Open Recruitment ini dapat dilihat di sekretariat UKM Maritime Challenge

…………………………………………… ... ………………………………. Departement/Faculty :………………………………..... …………………………………………… … Motivation joint with Maritime Challenge :………………………………. Surabaya Address :………………………………. Place/date of birth :………………………………………………………………………………. …………………………………………… … Address :………………………………... :………………………………... ……………………………………………. ……………………………………………. …………………………………………… . @ 2 sheet  All information about open recruitment can be seen in sekertariat of Maritime Challenge ... Nick name :……………………………………………………………… ………………. ….....series :……… ……………………………… …………………(commite include) Full name :……………………………………. Surabaya.....………..2012 3x4 (………………………………………) NRP………………………… Keterangan:  Include this form with capital words  This form can be copies  Back this form to the commite be self (can not be delegated)  Attachment 2 copies ITS student card  Collect photo size 3 x 4 and 4 x 6.…………………………………………… ……………. …………………………………………… … Hobbies :……………………………….. ………………………………... Mobil phone number :……………………………….. …………………………………………… … NRP :……………………... ……………………………………………. ……………………………………………. …………………………………………… … Phone number :……………………………….REGRISTRATION FORM UKM MARITIME CHALLENGE No. :……………………………….... ………………………………………...