form mahasiswa baru - Pendidikan Profesi Dokter Hewan
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FORMULIR PENDAFTARAN PROGRAM STUDI PENDIDIKAN PROFESI DOKTER HEWAN Sekretariat : Ruang Pengelola PPDH Fakultas Kedokteran Hewan Lantai 1 Jl. Fauna No.2, Karangmalang, Yogyakarta 55281 Telp: 0274-7480307 Website: http://ppdh.fkh.ugm.ac.id/web/ Email: [email protected] Nama : ………………………………………………………………… Tempel Foto Terbaru Berwarna 4x6 MAHASISWA BARU FORMULIR PENDAFTARAN PROGRAM PENDIDIKAN PROFESI DOKTER HEWAN FAKULTAS KEDOKTERAN HEWAN UNIVERSITAS GADJAH MADA DATA PRIBADI Nama Lengkap : ............................................................................................ Nomor Induk Mahasiswa : ............................................................................................. IPK Sarjana : ............................................................................................. Terdaftar pertama diUGM : ............................................................................................. Tanggal lulus sarjana : ............................................................................................. Tempat & tanggal lahir : Golongan Darah : Kab. /Propinsi.................................................................... Tgl. ..................................................................................... A B AB O Agama : .............................................................................................. Jenis Kelamin : Pria Wanita Status perkawinan : Nikah Belum Nikah Alamat rumah : (tempat tinggal tetap) Janda/Duda .............................................................................................. .............................................................................................. Kab. ...................................................................................... Propinsi ............................................................................... Nomor telepon : (............) ............................ HP. .......................................... Alamat sekarang : .............................................................................................. .............................................................................................. Kab. ...................................................................................... Propinsi ............................................................................... Nomor telepon : (............) ............................ HP. .......................................... E-mail : .............................................................................................. Alamat lain (orang : .............................................................................................. tua/saudara) yang bisa .............................................................................................. dihubungi .............................................................................................. Kab. ...................................................................................... Propinsi ............................................................................... Nomor telepon : (............) ............................ HP. .......................................... Asal Ijasah Sekolah : Nama Sekolah Tempat Sekolah Th. Ijasah SD : …………………… ………………… ………….. SMP : …………………… ………………… ………….. SMA : …………………… ………………… ………….. Judul Skripsi / tahun : .............................................................................................. .............................................................................................. .............................................................................................. Pembimbing : .............................................................................................. Yogyakarta, ………………………… (………………………………………) Nama Lengkap PROYEKSI KEINGINAN Proyeksi Keinginan untuk mengikuti Pendidikan Profesi di Program Pendidikan Profesi Dokter Hewan UGM adalah sebagai berikut: 1. Alasan mengikuti Pendidikan Profesi di Program Pendidikan Profesi Dokter Hewan UGM dengan pilihan program studi tersebut: ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... 2. Harapan yang diinginkan dari mengikuti Pendidikan Profesi di Program Pendidikan Profesi Dokter Hewan UGM: …....................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... 3. Rencana yang akan dilakukan setelah menyelesaikan Pendidikan Profesi di Program Pendidikan Profesi Dokter Hewan UGM Pascasarjana UGM: ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................
