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Nama *
Contoh : Nizam Takdirsyah
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Nim *
Contoh : 201410130311144
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Fakultas / Jurusan / Kelas *
Contoh : FKIP / PGSD / 1A
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Semester *
Tempat Lahir *
Contoh : Dompu, Nusa Tenggara Barat
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Tanggal Lahir *
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Alamat Asal *
Contoh : Kota Malang, Jawa Timur
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Alamat Di Malang *
Contoh : Jl. Raya Telogomas No. 246, Malang, Jawa Timur
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Nama Orang Tua *
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Alamat Orang Tua *
Contoh : Kota Malang, Jawa Timur
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No HP *
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No HP Orang Tua
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