FORMULIR PENDAFTARAN LKMM TM ITS 2019

BIODATA
Nama Lengkap : _____________________________________________________________
Nama Panggilan : _____________________________________________________________
Departemen / Fakultas : _____________________________________________________________
NRP : _____________________________________________________________ Foto
Tempat, Tanggal lahir : _____________________________________________________________ Beralmamater
Alamat Asal : _____________________________________________________________
3x4
Alamat Surabaya : _____________________________________________________________
No. Telp / HP : _____________________________________________________________
E-mail : _____________________________________________________________

KARAKTER

Tipe Kepribadian (MBTI):

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Kelebihan Diri :
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Kekurangan Diri :
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Motivasi mengikuti LKMM TM ITS 2018 :

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
RIWAYAT
Kepanitiaan
Tahun Nama Kegiatan Jabatan Penyelenggara

Pelatihan
Tahun Nama Pelatihan Penyelenggara

Organisasi
Tahun Organisasi Jabatan

Pendidikan
Tahun Jenjang Pendidikan Nama Instansi
SD
SMP
SMA
Perguruan Tinggi

Surabaya, ........................ 2019

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