Pas foto berwarna

ukuran 6x4 cm

FORMULIR DJARUM BEASISWA PLUS

Petunjuk :
1. Bacalah setiap pertanyaan dengan seksama dan istilah dengan huruf cetak
2. Berikan keterangan yang sesuai dengan keadaan yang sebenarnya

A. IDENTITAS
Nama Lengkap : ...........................................................................L/P*)
Tempat/tanggal Lahir : ...............................................................................
No.HP : ...............................................................................
Alamat Asal/Orang Tua : ...............................................................................
..............................................................................
RT/ RW : ............. Telp : ........................................
Alamat Sekarang/Kontrak/Kost : ................................................................................
...............................................................................
RT/ RW : ............. Telp : ........................................
Alamat E-mail : ................................................................................
Alamat Facebook : ................................................................................
Perguruan Tinggi / PT : ................................................................................
................................................................................
Kota / Alamat PT : ................................................................................
................................................................................
 Fakultas : ................................................................................
Jurusan : ...............................................................................
Semester : ...............................................................................
NIM : ...............................................................................
IPK Semester III : ...............................................................................
IPK Semester IV : ...............................................................................
Ukuran Baju : S , M , L , XL , XXL , XXXL *)

B. KELUARGA
Susunan Keluarga :
Orang Tua
Ayah Ibu

Nama

Usia

Pendidikan

Alamat

No.Telp : ..............................................
Anak ke..........................dari .......................saudara
Saudara Kandung
Nama Usia L/P Pendidikan Pekerjaan
C. PENDIDIKAN
Dasar dan Menengah
Tingkat Nama Sekolah Kota Tahun Lulus/Tidak Nilai

SD

SMP

SMU

Kursus/Training/Seminar
Topik Penyelenggara Tahun Keterangan

*) Lampirkan Fotocopy : Serifikat / ijazah / Tanda lulus

Penguasaan Bahasa Asing

Bahasa Tertulis Lisan

Kurang Cukup Baik Kurang Cukup Baik

D. MINAT
Apakah anda sedang menerima beasiswa lain? [ ] Tidak [ ] Ya
Mengapa Anda berminat untuk mendaftar dalam Beasiswa Djarum?.................................
...................................................................................................................................
Apakah yang anda ketahui tentang Beasiswa Djarum?.....................................................
...................................................................................................................................
...................................................................................................................................
Apakah yang anda ketahui tentang Djarum....................................................................
...................................................................................................................................
Bersediakan anda untuk aktif dalam kegiatan Beasiswa Djarum?
[ ] Tidak [ ] Ya
Berikan alasannya?........................................................................................................
....................................................................................................................................
....................................................................................................................................
Apakah anda tertarik dengan kegiatan sosial? [ ] Tidak [ ] Ya
Berikan alasannya?........................................................................................................
....................................................................................................................................
Jika anda tertarik dengan kegiatan sosial,jelaskan bentuk kegiatan sosial yang anda sukai?
...................................................................................................................................
...................................................................................................................................
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Bagaimana sikap anda jika mendapatkan tawaran dari beasiswa lain?...............................
....................................................................................................................................
....................................................................................................................................
Sebutkan keterampilan khusus yang dikuasai?................................................................
...................................................................................................................................
...................................................................................................................................
Sebutkan hobby atau kegemaran saudara?.....................................................................
...................................................................................................................................
...................................................................................................................................
E. AKTIFITAS SOSIAL DAN KEGIATAN LAIN
Apakah anda tertarik mengikuti kegiatan diluar jam kuliah? [ ] Tidak [ ] Ya
Jika Ya, kegiatan diluar kuliah apa yang paling menarik untuk diikuti dan mengapa?
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
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Jika Tidak, kenapa tidak tertarik untuk mengikuti kegiatan diluar kuliah?
...................................................................................................................................
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1. Kegiatan Dalam Kampus

Nama Jabatan Waktu Alasan Mengikuti

Organisasi/Kegiatan Keikutsertaan
2. Kegiatan Di Luar Kampus

Nama Jabatan Waktu Alasan Mengikuti

Organisasi/Kegiatan Keikutsertaan

3. Apakah anda mempunyai pekerjaan sampingan/part time?

Jika Ya, sebagai apa?...............................................................................................
..............................................................................................................................

Semua keterangan yang saya tuliskan pada formulir ini telah sesuai dengan keadaan
yang sebenarnya.

................................,...............

( , )
nama jelas
Interview : ................................ Tgl: .............................................
Catatan :