FORMULIR PENDAFTARAN

CALON PENGURUS ORGANISASI MAHASISWA

STIKES YARSI MATARAM
2018/2019

Nama : _______________________________________
Tempat, Tanggal Lahir : _______________________________________
Alamat Asal : _______________________________________
Alamat Kos/Kontarakan/Rumah : _______________________________________
Program Studi/Kelas/Tingkat : _______________________________________
Nomor Telp. & Whatsapp : _______________________________________
Motto Hidup : _______________________________________
Alamat
* Email : _______________________________________
* Instagram : _______________________________________
PENGALAMAN ORGANISASI :
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
5. ______________________________________________________________
ORGANISASI YANG AKAN DIIKUTI:
 BADAN EKSEKUTIF MAHASISWA (BEM)
 HIMPUNAN MAHASISWA (HIMA) S1 KEPERAWATAN
 HIMPUNAN MAHASISWA (HIMA) D3 KEPERAWATAN
 HIMPUNAN MAHASISWA (HIMA) D3 KEBIDANAN
MOTIVASI MENGIKUTI ORGANISASI:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
SARAN PROGRAM KERJA:
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
4. ______________________________________________________________________

Mataram,…………., Oktober 2018

Calon Pengurus
3x4
(…………………………………….)
NIM :