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DATA MAHASISWA TBI UIN MATARAM
Isilah formulir berikut sesuai dengan data diri anda selengkapnya
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Email
*
Your email
Nama Lengkap
*
Your answer
NIM
*
Your answer
Jenis Kelamin
*
Laki-Laki
Perempuan
Tempat Lahir (Kota)
*
Your answer
Tanggal Lahir
*
MM
/
DD
/
YYYY
Alamat Rumah
*
Your answer
Alamat Kos (Alamat di Mataram)
*
Your answer
No. Telepon (HP)
*
Your answer
No. Telepon Rumah (Bila )
*
Your answer
Nama Ayah
*
Your answer
Pekerjaan Ayah
*
PNS
Wiraswasta
Lainya
Nama Ibu
*
Your answer
Pekerjaan Ibu
*
Your answer
Email Aktif
*
Your answer
Hobi/Kegemaran
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Your answer
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