Formulir Pendaftaran OR LKIM 2011
N a m a : ______________________________________________
NO. BP : ______________________________________________
Jurusan : ______________________________________________
Jenis Kelamin : ______________________________________________
TTL : ______________________________________________
NO. Telp/Hp : ______________________________________________
Alamat di Padang : ______________________________________________
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Alamat di Tempat Asal : ______________________________________________
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Agama : ______________________________________________
e-mail : ______________________________________________
website/weblog : ______________________________________________
Penghargaan yg pernah diraih : (sebutkan judul, tahun, tingkat dan acaranya)
1 ______________________________________________
2 ______________________________________________
3 ______________________________________________
Karya Ilmiah yang pernah dibuat : (sebutkan judul, tahun, tingkat dan acaranya)
1 ______________________________________________
2 ______________________________________________
3 ______________________________________________
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