FORMULIR PENDAFTARAN

CALON KETUA BADAN EKSEKUTIF MAHASISWA PERIODE 2010-2011

SEKOLAH TINGGI ILMU KESEHATAN BUDI LUHUR CIMAHI

Isilah formulir ini sesuai dengan data diri anda yang sebenar-benarnya:

BIODATA

Nama Lengkap : ......................................................................................................

Nama Panggilan : ......................................................................................................
Jenis Kelamin : ......................................................................................................
Tempat & Tanggal Lahir : ......................................................................................................
Agama : ......................................................................................................
Alamat
- Rumah : ......................................................................................................
- Kos : ......................................................................................................
No. Telp Rumah/Kost/HP : ......................................................................................................
E-mail
Hobby
Motto Hidup

RIWAYAT PENGALAMAN ORGANISASI

No Nama Organisasi Jabatan Organisasi Periode/Tahun
1
2
3
4
5
6

RIWAYAT PENGALAMAN KEPANITIAAN

No Nama Kepanitiaan Jabatan Dalam Kepanitiaan Periode/Tahun
1
2
3
4
5
6
7
8
9
10
RIWAYAT PENGALAMAN SEMINAR/TRAINING/WORKSHOP
Peran Dalam
No Nama Kepanitiaan Penyelenggara Periode/Tahun
Kegiatan
1
2
3
4
5
6
Contoh: Pembicara, MC/Moderator, Trainer, Relawan, Anggota, dan Lain-lain

Fasilitas Yang Dimiliki

( ) Komputer

( ) Laptop

( ) Motor

( ) Lain-lain

DESKRIPSI DIRI

Menurut saya, lima kelemahan yang saya miliki adalah:

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

Menurut Saya, Lima kelebihan yang saya miliki adalah:

1. ......................................................................................................................................
2. ......................................................................................................................................
3. ......................................................................................................................................
4. ......................................................................................................................................
5. ......................................................................................................................................
Alasan Mencalonkan Diri Sebagai Ketua Badan Eksekutif Mahasiswa

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

VISI

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MISI

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Saya yang bertanda tangan dibawah ini menyatakan bahwa tidak ada rekayasa dalam pengisian data
dan formulir ini. Saya telah mencantunkan data tersebut dengan sebenar-benarnya dan sejujur-
jujurnya

Cimahi, Maret 2011

Ttd,

(.........................................)
NIM. ..................................