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<font size="5"><b>UNIVERSITAS SRIWIJAYA</b></font><br />
<font size="5"><b>KARTU INDUK DATA MAHASISWA</b></font><br />
<font size="5"><b>TA. 2013/2014</b></font><br />
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<table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f
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<td>Nama</td>
<td>:</td>
<td><strong>BILLI ATTRA</strong></td>
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<td>Nomor Pendaftaran</strong></td>
<td>:</td>
<td><strong>5132400111</strong></td>
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<td>Program Studi </td>
<td>:</td>
<td>
KESEKRETARIATAN </td>
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<td valign="top">Strata Pendidikan</td>
<td valign="top">:</td>
<td>
Diploma-III (D3)
</td>
</tr>
<tr>
<td valign="top">UKT (Uang Kuliah Tunggal) Yang Harus Dibayar</td>
<td valign="top">:</td>
<td>
<b>Rp. 4.400.000,00</b> </td>
</tr>
<tr>
<td valign="top">Bank Tempat Pembuatan KPM</td>
<td valign="top">:</td>
<td>
<strong>BANK SUMSEL BABEL</strong>
</td>
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<td colspan="3">&nbsp;</td>
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1. DATA PRIBADI
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</tr> <tr> <td valign="top">Tempat Lahir</td> <td valign="top">:</td> <td> PALEMBANG </td> </tr> <tr> <td valign="top">Tanggal Lahir</td> <td valign="top">:</td> <td> 27 Januari 1993 </td> </tr> <tr> <td valign="top">Tinggi Badan (cm)</td> <td valign="top">:</td> <td> 182 cm </td> </tr> <tr> <td valign="top">Jenis Kelamin</td> <td valign="top">:</td> <td> LAKI-LAKI </td> </tr> <tr> <td valign="top">Golongan Darah</td> <td valign="top">:</td> <td> O </td> </tr> <tr> <td valign="top">Penyakit penting yang pernah dialami</td> <td valign="top">:</td> <td> TIDAK ADA </td> </tr> <tr> <td valign="top">Agama</td> <td valign="top">:</td> <td> ISLAM </td> </tr> <tr> <td valign="top">Anak Nomor Ke-</td> <td valign="top">:</td> <td> 2 dari 3 orang bersaudara </td> </tr> <tr> <td valign="top">Kewarganegaraan</td> <td valign="top">:</td> <td> INDONESIA ASLI </td> </tr> <tr> .

PLAJU. sebagai: </td> </tr> <tr> <td valign="top">Pendapatan/bulan (Rp)</td> <td valign="top">:</td> <td> Rp. sans-serif. AHMAD YANI KOMPLEK PERMATA BIRU BLOK E NO 3. font-size:11px"> <tr> <th>Tingkat</th> <th>Nama Sekolah</th> <th>Jurusan</th> <th>Lokasi Kab/Kodya/Prop</th> <th>Tahun Lulus</th> </tr> <tr> .<td valign="top">Alamat Tinggal Selama Mengikuti Pendidikan</td> <td valign="top">:</td> <td> JLN. sans-serif. font-size:11px"> <tr> <th align="left"> 2. SUMATERA SELATAN </td> </tr> <tr> <td valign="top">No. Helvetica. memiliki anak: 0 orang </td> </tr> <tr> <td valign="top">Pekerjaan</td> <td valign="top">:</td> <td> BELUM BEKERJA.00 </td> </tr> </table> <br /> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial. DATA PENDIDIKAN <hr size="1px"> </th> </tr> </table> <table border="1" width="100%" cellpadding="0" cellspacing="0" style="font-famil y: Arial. Telepon/HP</td> <td valign="top">:</td> <td> 085208693500 </td> </tr> <tr> <td valign="top">Status</td> <td valign="top">:</td> <td> BELUM KAWIN. 0. KOTA PALEMBANG. Helvetica.

Jumlah Mata Pelajaran</td> <td>:</td> <td> 13 </td> </tr> . Helvetica. Nomor Ijazah</td> <td>:</td> <td> DN-11 Ma 0000680 </td> </tr> <tr> <td>c.<td>SD</td> <td align="center"> SD MUHAMMADIYAH 16 <td align="center"> </td> <td align="center"> PALEMBANG </td> <td align="center"> 2006 </td> </td> </tr> <tr> <td>SLTP</td> <td align="center"> SMP N 16 </td> <td align="center"> </td> <td align="center"> PALEMBANG </td> <td align="center"> 2009 </td> </tr> <tr> <td>SLTA</td> <td align="center"> SMA N 08 PALEMBANG </td> <td align="center"> IPS </td> <td align="center"> KOTA PALEMBANG. sans-serif. font-size:11px"> <tr> <td rowspan="4">Ijazah & Nilai Akademik Pendidikan Terakhir</td> <td>a. Tahun Lulus</td> <td>:</td> <td> 2012 </td> </tr> <tr> <td>b. SUMATERA SELATAN </td> <td align="center"> 2012 </td> </tr> </table> <br /> <table border="1" width="100%" cellpadding="0" cellspacing="0" style="font-famil y: Arial.

PENGALAMAN ORGANISASI <hr size="1px"> </th> </tr> </table> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial.16 </td> </tr> <tr> <td rowspan="2">Nilai Ujian Nasional</td> <td>a. font-size:11px"> <tr> <th align="left">3. sans-serif.9 </td> </tr> </table> <br /> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial. Helvetica. Nilai Rata-Rata</td> <td>:</td> <td> 7. sans-serif. Nilai Rata-Rata/IPK</td> <td>:</td> <td> 8. Helvetica. Jumlah Mata Pelajaran</td> <td>:</td> <td> 6 </td> </tr> <tr> <td>b.<tr> <td>d. font-size:11px"> <tr> <td colspan="3"><strong>Organisasi Intra Sekolah</strong></td> </tr> <tr> <td>Nama Organisasi</td> <td>:</td> <td> </td> </tr> <tr> <td>Tahun</td> <td>:</td> <td> </td> </tr> <tr> <td>Jabatan</td> <td>:</td> <td> </td> </tr> <tr> <td colspan="3"><strong>Organisasi Ekstra Sekolah</strong></td> </tr> <tr> <td>Nama Organisasi</td> .

Helvetica. Helvetica. sans-serif. PRESTASI/PENGHARGAAN/TANDA JASA <hr size="1px"> </th> </tr> </table> <table border="1" width="100%" cellpadding="0" cellspacing="0" style="font-famil y: Arial.<td>:</td> <td> PALANG MERAH REMAJA </td> </tr> <tr> <td>Tahun</td> <td>:</td> <td> 2012 </td> </tr> <tr> <td>Jabatan</td> <td>:</td> <td> KOORDINATOR LAPANGAN (ANGGOTA) </td> </tr> </table> <br /> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial. font-size:11px"> <tr> <th>Tingkat</th> <th>Bidang</th> <th>Sebagai</th> <th>Tahun Lulus</th> </tr> <tr> <td>Sekolah</td> <td align="center"> PALANG MERAH REMAJA </td> <td align="center"> ANGGOTA </td> <td align="center"> 2010 </td> </tr> <tr> <td>Daerah</td> <td align="center"> </td> <td align="center"> </td> <td align="center"> </td> </tr> <tr> <td>Nasional</td> <td align="center"> </td> <td align="center"> </td> . font-size:11px"> <tr> <th align="left">4. sans-serif.

font-size:11px"> <tr> <th align="left">6. sans-serif.<td align="center"> </td> </tr> <tr> <td>Internasional</td> <td align="center"> </td> <td align="center"> </td> <td align="center"> </td> </tr> </table> <br /> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial. font-size:11px"> <tr> <th align="left">5.</td> <td> </td> </tr> <tr> <td>2. Helvetica. sans-serif. sans-serif. Helvetica. Helvetica. sans-serif. font-size:11px"> <tr> <td colspan="3"><strong>AYAH</strong></td> </tr> <tr> <td>Nama</td> <td>:</td> <td> RACHMAN CIKMAT </td> </tr> <tr> <td>Pekerjaan</td> . font-size:11px"> <tr> <td>1.</td> <td> </td> </tr> </table> <br /> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial. Helvetica. BAKAT/HOBI/KEGEMARAN <hr size="1px"> </th> </tr> </table> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial. DATA KELUARGA <hr size="1px"> </th> </tr> </table> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial.

HP</td> <td>:</td> <td> 085267947777 </td> </tr> </table> <br /> <br /> <table border="0" width="100%" cellpadding="5px" cellspacing="5px" style="font-f amily: Arial.00 </td> </tr> <tr> <td>Alamat Rumah</td> <td>:</td> <td> JLN. Helvetica. font-size:11px"> <tr> <td colspan="3"><strong>IBU</strong></td> </tr> <tr> <td>Nama</td> <td>:</td> <td> . AHMAD YANI KOMPLEK PERMATA BIRU BLOK E NO 3. Telp</td> <td>:</td> <td> 0711-517752 </td> </tr> <tr> <td>No.<td>:</td> <td> SWASTA </td> </tr> <tr> <td>Tempat Lahir</td> <td>:</td> <td> TULUNG SELAPAN .OKI </td> </tr> <tr> <td>Tanggal Lahir</td> <td>:</td> <td> 02 Januari 1964 </td> </tr> <tr> <td>Pendidikan Terakhir</td> <td>:</td> <td> SMA </td> </tr> <tr> <td>Penghasilan Sebulan (Rp)</td> <td>:</td> <td> Rp. SUMATERA SELATAN </td> </tr> <tr> <td>No. PLAJU.000.000. 7. sans-serif. KOTA PALEMBANG.

OKI </td> </tr> <tr> <td>Tanggal Lahir</td> <td>:</td> <td> 10 Oktober 1968 </td> </tr> <tr> <td>Pendidikan Terakhir</td> <td>:</td> <td> SMA </td> </tr> <tr> <td>Penghasilan Sebulan (Rp)</td> <td>:</td> <td> Rp. Telp</td> <td>:</td> <td> 0711-517752 </td> </tr> <tr> <td>No. PLAJU. AHMAD YANI KOMPLEK PERMATA BIRU BLOK E NO 3. HP</td> <td>:</td> <td> 08287101104 </td> </tr> </table> <!-<br /> .000. 3.000.00 </td> </tr> <tr> <td>Alamat Rumah</td> <td>:</td> <td> JLN. SUMATERA SELATAN </td> </tr> <tr> <td>No. KOTA PALEMBANG.MULYANA </td> </tr> <tr> <td>Pekerjaan</td> <td>:</td> <td> SWASTA </td> </tr> <tr> <td>Tempat Lahir</td> <td>:</td> <td> SUNGAI JERUJU .

font-size:10pt.<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <table width="100%" align="center" cellspacing="0" cellpadding="0" style="font-f amily: Arial.</td> <td>Jalur Seleksi</td> .p Kepala BAAK <br /> Universitas Sriwijaya </p> <p style="font-family: Arial."> Saya yang bertanda tangan di bawah ini: </p> <table width="100%" style="font-family: Arial.</td> <td>Nama</td> <td>:</td> <td>BILLI ATTRA</td> </tr> <tr> <td>b.</td> <td>Asal SMU</td> <td>:</td> <td></td> </tr> <tr> <td>d. Rektor <br /> u.</td> <td>Alamat SMU</td> <td>:</td> <td></td> </tr> <tr> <td>e. font-size:10pt. font-size:12pt.</td> <td>Tempat/Tanggal Lahir</td> <td>:</td> <td>PALEMBANG / 27 Januari 1993</td> </tr> <tr> <td>c."> <tr> <td align="center"> <font size="3"><b>FORMULIR REGISTRASI</b></font><br /> <font size="3"><b>MAHASISWA BARU UNIVERSITAS SRIWIJAYA</b></fo nt><br /> <font size="3"><b>TAHUN AKADEMIK 2013/2014</b></font><br /> </td> </tr> </table> <hr> <p style="font-family: Arial."> Kepada Yth."> <tr> <td>a. font-size:10pt.

</td> </tr> <tr> <td>b."> <tr> <td>Program Studi</td> <td>:</td> <td> KESEKRETARIATAN </td> </tr> <tr> <td>Strata Pendidikan</td> <td>:</td> <td>S1 (Strata 1)</td> </tr> </table> <p style="font-family: Arial. Telepon/HP</td> <td>:</td> <td>085208693500</td> </tr> </table> <p style="font-family: Arial.</td> <td>Bukti pemeriksaan kesehatan dan bebas narkoba dari UPT Klinik Unsri. font-size:10pt. AHMAD YANI KOMPLEK PERMATA BIRU BLOK E NO 3.</td> <td>No. </td> </tr> <tr> <td valign="top">c.</td> <td>No. PLAJU."> <tr> <td>a. KOTA PALEMB ANG.<td>:</td> <td>USM 2013</td> </tr> <tr> <td>f."> Terlampir kami sampaikan berkas persyaratan sebagai berikut: </p> <table width="100%" style="font-family: Arial. font-size:10pt. font-size:10pt. Kartu Data Induk . font-size:10pt.</td> <td>Foto copy ijazah terakhir yang telah dilegalisir. SUMATERA SELATAN</td> </tr> <tr> <td>h.</td> <td> Formulir berkas registrasi (Surat Pernyataan Mahasiswa."> Bermaksud melaksanakan registrasi sebagai mahasiswa Universitas Sriwijaya: </p> <table width="100%" style="font-family: Arial. Test</td> <td>:</td> <td>5132400111</td> </tr> <tr> <td>g.</td> <td>Alamat Tinggal</td> <td>:</td> <td>JLN.

.</td> </tr> <tr> <td align="right">BILLI ATTRA</td> </tr> <tr> <td align="right"></td> </tr> </table> --> ........ sebutkan ............................"> <tr> <td align="right">Indralaya..............</td> </tr> <tr> <td align="right">Calon mahasiswa....</td> <td> Lain-lain....... ....................................... </td> </tr> <tr> <td valign="top">d.......... font-size:10pt.Mahasiswa.</td> </tr> <tr> <td align="right">&nbsp....................... Blanko Pembuatan Kartu Pengenal Mahasiswa/KPM)............... <br /> <br /> <br /> <br /> <br /> </td> </tr> </table> <table width="100%" style="font-family: Arial.. ybs.......... ...........

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