KOMANDO RESIMEN MAHASISWA

UNIVERSITAS LABUHANBATU
Jl. Sisingamangaraja No.126 A KM 3.5 Aek Tapa Bakaran Batu Rantau Sel Kabupaten Labuhan Batu Sumatra Utara

FORMULIR PENDAFTARAN
KOMANDO RESIMEN MAHASISWA
UNIVERSITAS LABUHANBATU
Nama Lengkap :………………………………………………………………………………………………………………

Tempat / Tanggal Lahir :………………………………………………………………………………………………………………..

Alamat :………………………………………………………………………………………………………………..

Nomor Hp/No. Wa :………………………………………………………………………………………………………………..

Jenis Kelamin :……………………………………………………………………………………………………………….

Agama :………………………………………………………………………………………………………………..

Gol. Darah :………………………………………………………………………………………………………………

Riwayat Penyakit :………………………………………………………………………………………………………………

Tinggi/ Berat Badan :………………………………………………………………………………………………………………..

Nama Orang Tua/Wali :……………………………………………………………………………………………………………….

Alamat Ortu / Wali :………………………………………………………………………………………………………………

No. Hp / WA Ortu :………………………………………………………………………………………………………………

Fakultas/Jurusan :………………………………………………………………………………………………………………

NIM :………………………………………………………………………………………………………………..

Pendaftar

Rantauprapat,

…………………………………..

NIM.