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FORMULIR PENDAFTARAN

PEMILIHAN PUTRA PUTRI DUTA TEKNOLOGI PERTANIAN


FAKULTAS TEKNOLOGI PERTANIAN
UNIVERSITAS GADJAH MADA
TAHUN 2013
Pas Foto

Nama

4x6
: ....................................................................................................

NIM

: ....................................................................................................

Jurusan

: ....................................................................................................

Tahun masuk

: ....................................................................................................

Jenis Kelamin

: [L] / [P]

Tempat/tanggal lahir

: ....................................................................................................

Alamat

: ....................................................................................................
: ....................................................................................................

Nomor HP

: ....................................................................................................

Email

: ....................................................................................................

Facebook/twitter

: ....................................................................................................

Tinggi Badan

: .............cm

Berat Badan

: .............kg

Hobi

: ....................................................................................................

Prestasi yang dimiliki

: 1. .................................................................................................
: 2. ................................................................................................
: 3. .................................................................................................
: 4. ................................................................................................
: 5. ................................................................................................

Kegiatan kampus/luar kampus

: 1. .................................................................................................

yang diikuti

: 2. ................................................................................................
: 3. .................................................................................................

Peserta

................................................