UNIVERSITAS MUHAMMADIYAH PALU

REGISTRASI DAN HERREGISTRASI MAHASISWA

No. .......................................
I. IDENTITAS DIRI
Nama : .............................................................................................................
Tempat Tanggal Lahir : .............................................................................................................
Jenis Kelamin : .............................................................................................................
Agama : .............................................................................................................
Hobi/Minat/Bakat : .............................................................................................................
Alamat Sekarang : .............................................................................................................
Pekerjaan / Instansi : .............................................................................................................
II. ALAMAT
No. KTP : .............................................................................................................
Jalan : .............................................................................................................
Desa / Kelurahan : .............................................................................................................
Kecamatan : .............................................................................................................
Kabupaten / Kota : .............................................................................................................
Kewarganegaraan : .............................................................................................................
Jenis Tinggal : Bersama Orang Tua, Wali, Kost, Asrama, dan Lainnya
Telp. Rumah : .............................................................................................................
No. HP/WA : .............................................................................................................
Email : .............................................................................................................
III. STATUS PENDAFTARAN
Terdaftar pada Fakultas : .............................................................................................................
Nomor Stambuk : .............................................................................................................
Jurusan / Program Studi : .............................................................................................................
Status Kemahasiswaan : Baru, Pindahan, Melanjutkan
Mutasi dari PTN/PTS : .............................................................................................................
a. Fakultas : .............................................................................................................
b. Jurusan/Prodi : .............................................................................................................
Alasan Mutasi : .............................................................................................................
IV. ORANG TUA
Nama Ayah : .............................................................................................................
Tempat Tanggal Lahir : .............................................................................................................
Pendidikan Terakhir : .............................................................................................................
Pekerjaan dan No.Hp./WA : ........................................................................................
Jumlah Penghasilan/Bulan : .............................................................................................................
Nama Ibu Kandung : .............................................................................................................
Tempat Tanggal Lahir : .............................................................................................................
Pendidikan Terakhir : .............................................................................................................
Pekerjaan dan No.Hp./WA : .............................................................................................................
Jumlah Penghasilan/Bulan : .............................................................................................................
Nama Wali : .............................................................................................................
Tempat Tanggal Lahir : .............................................................................................................
Pendidikan Terakhir : .............................................................................................................
Pekerjaan dan No.Hp./WA : .............................................................................................................
Jumlah Penghasilan/Bulan : .............................................................................................................
Catatan: Coret yang Tidak Perlu
Palu, ............................ 20....
Mahasiswa Ybs
PERSYARATAN PENDAFTARAN ULANG:
1. Mengisi Formulir (Herregistrasi BAAK), Fotocopy 1 Lembar
2. Foto Copy Ijazah Terakhir Dilegalisir 3 Lembar Foto
3. Foto Copy KTP, Kartu Keluarga, Akte Kelahiran (@ 2 Lembar) 2x3
4. Pas Foto Ukuran
a. 2 x 3 = 3 Lembar
b. 3 x 4 = 4 Lembar ...............................................
5. Surat Izin Belajar Bagi PNS 2 Lembar Keterangan
6. Surat Keterangan Pindah dan Nilai Akademik Record 1. Lembar Putih untuk BAAK
yang disahkan dari PT asal masing-masing 2 Rangkap 2. Lembar Hijau untuk Fakultas
7. Foto Copy Bukti Bayar, SPP, dll 4 Lembar dan Memperlihatkan Asli 3. Lembar Kuning untuk Mahasiswa