Form Pendataan Mahasiswa Terdampak Gempa dan Tsunami PALU
Isilah form dibawah ini untuk kelengkapan administrasi pendataan
NIK *
Your answer
NIM *
Your answer
Nama Mahasiswa *
Your answer
Kode Prodi *
Your answer
Nama Prodi *
Your answer
ID Jenjang (D3=3 & S1=5) *
Semester *
Your answer
Kode Perguruan Tinggi *
Your answer
Perguruan Tinggi *
Your answer
Jenis Kelamin *
Tanggal Lahir *
MM
/
DD
/
YYYY
Kota Lahir *
Your answer
Ibu Kandung *
Your answer
Pekerjaan *
Your answer
Jumlah Tanggungan *
Your answer
Penghasilan *
Your answer
Alamat Lengkap *
Your answer
Kota *
Your answer
Kelurahan *
Your answer
Kecamatan *
Your answer
Provinsi *
Your answer
Kode Pos *
Your answer
No. Telepon *
Your answer
NISN (Nomor Induk Siswa Nasional) *
Your answer
Submit
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