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<meta name="author" content="mafni" />
<title>BIDIK MISI</title>
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<img align="left" src="D:/BIDIK MIS.PNG" width="140" height="60" />
<b><h3 align="center">LAMPIRAN 3:FORMULIR PENDAFTARAN</h3></h3>
<h3 align="center"> PROGRAM BIDIKMISI DIKTI KEMDIKBUD 2013 </h3>
<p align="center"> (formulir diisi dengan huruf kapital) </p>
</body>
<table>
<form>
<b><h3>I. DATA DIRI</h3></b>
<tr>
<td>1.</td><td>NAMA LENGKAP</td><td>:</td><td><input size="75" type="text"name="nama pertama"/></td><br/>
</tr>
<tr>
<td>2.</td><td>JENIS KELAMIN</td><td>:</td><td><input type="radio" name="receive_at" value="1">Laki-laki<input type="radio" name="receive_at"value="2">Perempuan</td><br />
</tr>
<tr>
<td>3.</td><td>AGAMA</td><td>:</td><td><select name="Agama"id="agama">
<option value="1" label=""></option>
<option value="1" label="Islam">Islam</option>
<option value="1" label="Kristen">Kristen</option>
<option value="1" label="Hindu">Hindu</option>
<option value="1" label="Konghucu">Konghucu</option>
<option value="1" label="Protestan">Protestan</option>
<option value="1" label="Katolik">Katolik</option></td>
</tr>
<tr>
<td>4.</td><td>KAB/KOTA LAHIR</td><td>:</td><td><input size="75" type="text"name="KAB"/></td>
</tr>
<tr>
<td>5.</td><td>TANGGAL LAHIR</td><td>:</td><td>: <select name="tanggal">
<option></option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
</select>
<select name="bulan">
<option></option>
<option>Januari</option>
<option>Februari</option>
<option>Maret</option>
<option>April</option>
<option>Mei</option>
<option>Juni</option>
<option>Juli</option>
<option>Agustus</option>
<option>September</option>
<option>Oktober</option>
<option>November</option>
<option>Desember</option>
</select>
<select name="tahun">
<option></option>
<option>1981</option>
<option>1982</option>
<option>1983</option>
<option>1984</option>
<option>1985</option>
<option>1986</option>
<option>1987</option>
<option>1988</option>
<option>1989</option>
<option>1990</option>
<option>1991</option>
<option>1992</option>
<option>1993</option>
<option>1994</option>
<option>1995</option>
<option>1996</option>
<option>1997</option>
<option>1998</option>
<option>1999</option>
<option>2000</option>
<option>2001</option>
<option>2002</option>
<option>2003</option>
<option>2004</option>
<option>2005</option>
<option>2006</option>
<option>2007</option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
</select></td>
</tr>
<tr>
<td>6.</td><td>ALAMAT</td><td>:</td><td><input size="75" type="text"/></td><br/>
</tr>
<tr>
<td>7.</td><td>KODE POS</td><td>:</td><td><input size="25" type="text"/></td><br/>
</tr>
<tr>
<td>8.</td><td>TELEPON RUMAH</td><td>:</td><td><input type="text"/>-<input size="30" type="text"/></td><td>(KODE WILAYAH-NOMOR TELEPON</td><br/>
</tr>
<tr>
<td>9.</td><td>HP</td><td>:</td><td><input type="text"/></td><br />
</tr>
</table>
<b><h3>II. KELUARGA</h3></b>
<table>
<tr>
<td>1.</td><td>NAMA AYAH/WALI</td><td>:</td><td><input size="40" type="text"/></td><br />
</tr>
<tr>
<td>2.</td><td>PEKERJAAN AYAH/WALI</td><td>:</td><td><select name="PEKERJAAN"id="PEKERJAAN">
<option value="1" label="PNS">PNS</option>
<option value="1" label="Peg. swasta">Peg. swasta</option>
<option value="1" label="Wirausaha">Wirausaha</option>
<option value="1" label="TNI/POLRI">TNI/POLRI</option>
<option value="1" label="Petani">Petani</option>
<option value="1" label="Nelayan">Nelayan</option></td><td>lainya</td><td><input type="text"/></td><br />
</tr>
<tr>
<td>3.</td><td>NAMA IBU</td><td>:</td><td><input size="40" type="text"/></td><br />
</tr>
<tr>
<td>4.</td><td>PEKERJAAN IBU</td><td>:</td><td><select name="PEKERJAAN"id="PEKERJAAN">
<option value="1" label="PNS">PNS</option>
<option value="1" label="Peg. swasta">Peg. swasta</option>
<option value="1" label="Wirausaha">Wirausaha</option>
<option value="1" label="TNI/POLRI">TNI/POLRI</option>
<option value="1" label="Petani">Petani</option>
<option value="1" label="Nelayan">Nelayan</option></td><td>lainya</td><td><input type="text"/></td><br />
</tr>
<tr>
<td>5.</td><td>JUMLAH TANGUNGGAN</td><td>:</td><td><input size="25" type="text"/></td></td><td>ORANG</td><br />
</tr>
<tr>
<td>6.</td><td>HP ORANG TUA</td><td>:</td><td><input size="40" type="number"/></td><br />
</tr>
<tr>
<td>7.</td><td>STATUS ORANG TUA</td><td>:</td><td>AYAH<td><select name="STATUS"id="STATUS">
<option value="1" label=""></option>
<option value="1" label="Kandung">Kandung</option>
<option value="1" label="Tiri">Tiri</option>
<option value="1" label="Angkat">Angkat</option>
<option value="1" label="Lainya">Lainya</option></td><td>IBU</td><td><select name="STATUS"id="STATUS">
<option value="1" label=""></option>
<option value="1" label="Kandung">Kandung</option>
<option value="1" label="Tiri">Tiri</option>
<option value="1" label="Angkat">Angkat</option>
<option value="1" label="Lainya">Lainya</option></td><br />
</tr>
<tr>
<td>8.</td><td>PENDIDIKAN ORANG TUA</td><td>:</td><td>AYAH</td><td><select name="PENDIDIKAN"id="PENDIDIKAN">
<option value="1" label=""></option>
<option value="1" label="Tidak Sekolah">Tidak Sekolah</option>
<option value="1" label="SD/MI">SD/MI</option>
<option value="1" label="SMP/MTS">SMP/MTS</option>
<option value="1" label="SMA/SMK">SMA/SMK</option>
<option value="1" label="D1">D1</option>
<option value="1" label="D2/D3">D2/D3</option>
<option value="1" label="S1/D4">S1/D4</option></td><td>IBU</td><td><select name="PENDIDIKAN"id="PENDIDIKAN">
<option value="1" label=""></option>
<option value="1" label="Tidak Sekolah">Tidak Sekolah</option>
<option value="1" label="SD/MI">SD/MI</option>
<option value="1" label="SMP/MTS">SMP/MTS</option>
<option value="1" label="SMA/SMK">SMA/SMK</option>
<option value="1" label="D1">D1</option>
<option value="1" label="D2/D3">D2/D3</option>
<option value="1" label="S1/D4">S1/D4</option></td><br />
</tr>
<tr>
<td>9.</td><td>ORANG TUA KANDUNG</td><td>:</td><td>AYAH</td><td><select name="PENDIDIKAN"id="PENDIDIKAN">
<option value="1" label=""></option>
<option value="1" label="Masih hidp">Masih hidup</option>
<option value="1" label="Sudah wafat">Sudah Wafat</option></option>
<option value="1" label="Lainya">Lainya</option></td><td>IBU</td><td><select name="PENDIDIKAN"id="PENDIDIKAN">
<option value="1" label=""></option>
<option value="1" label="Masih hidp">Masih hidup</option>
<option value="1" label="Sudah wafat">Sudah Wafat</option></option>
<option value="1" label="Lainya">Lainya</option></td><br />
</tr>
</table>
<b><h3>III.RUMAH TINGGAL KELUARGA</h3></b>
<table>
<tr>
<td>1.</td><td>KEPEMILIKAN</td><td>:</td><td><select name="KEPEMILIKAN"id="KEPEMILIKAN">
<option value="1" label=""></option>
<option value="1" label="Sendiri">SENDIRI</option>
<option value="1" label="Sewa Tahunan">Sewa Tahunan</option>
<option value="1" label="Sewa bulanan">Sewa Bulanan</option>
<option value="1" label="Menumpang">Menumpang</option>
<option value="1" label="Tidak Memiliki">Tidak Melmiliki</option>
<option value="1" label="Menumpang dan Tidak memiliki">Menumpang dan Tidak memiliki</option></td><br />
</tr>
<tr>
<td>2.</td><td>TAHUN PEROLEHAN</td><td>:</td><td><input size="25" type="text"/></td> <br />
</tr>
<tr>
<td>3.</td><td>SUMBER LISTRIK</td><td>:</td><td><select name="SUMBER LISTRIK"id="">
<option value="1" label=""></option>
<option value="1" label="PLN">PLN</option>
<option value="1" label="Genset/Mandiri">Genset/Mandiri</option>
<option value="1" label="PLN dan Genset">PLN dan Genset</option>
<option value="1" label="Tidak Ada">Tidak Ada</option></td><br />
</tr>
<tr>
<td>4.</td><td>LUAS TANAH</td><td>:</td><td><select name="Luas Tanah"id="">
<option value="1" label=""></option>
<option value="1" label="Lebih dari 200 M Persegi">Lebih dari 200 M Persegi</option>
<option value="1" label="Antara 100 M-200 M Persegi">Antara 100M-200 M Persegi</option>
<option value="1" label="Antara 50 M-99 M Persegi">Antara 50M-99 M Persegi</option>
<option value="1" label="Antara 25 M-50 Persegi">Antara 25M-50 Persegi</option>
<option value="1" label="Kurang Dari 25 M Persegi">Kurang Dari 25M Persegi</option></td><br />
</tr>
<tr>
<td>5.</td><td>LUAS BANGUNAN</td><td>:</td><td><select name="Luas Tanah"id="">
<option value="1" label=""></option>
<option value="1" label="Lebih dari 200 M Persegi">Lebih dari 200 M Persegi</option>
<option value="1" label="Antara 100 M-200 M Persegi">Antara 100M-200 M Persegi</option>
<option value="1" label="Antara 50 M-99 M Persegi">Antara 50M-99 M Persegi</option>
<option value="1" label="Antara 25 M-50 Persegi">Antara 25M-50 Persegi</option>
<option value="1" label="Kurang Dari 25 M Persegi">Kurang Dari 25M Persegi</option></td><br />
</tr>
<tr>
<td>6.</td><td>MANDI CUCI KAKUS</td><td>:</td><td><select name="MANDI CUCI KAKUS"id="">
<option value="1" label=""></option>
<option value="1" label="Kepemilikan Sendiri Didalam">Kepemilikan Sendiri Didalam</option>
<option value="1" label="Kepemilikan Sendiri Diluar">Kepemilikan Sendiri Diluar</option>
<option value="1" label="Berbagai Pakai"></option>Berbagai Pakai</td> <br />
</tr>
<tr>
<td>7.</td><td>SUMBER AIR</td><td>:</td><td><input type="radio" name="receive_at" value="1">Kemasan<input type="radio" name="receive_at"value="2">PDAM<input type="radio" name="receive_at"value="2">sumur<input type="radio" name="receive_at"value="3">Sungai/Mata Air Gunung</td><br />
</tr>
<tr>
<td>8.</td><td>JARAK DARI PUSAT KOTA</td><td>:</td><td><input size="30" type="number"/></td><td>KM</td><br />
</tr>
</table>
<p align="center">Lampiran 2:Formulir Pendaftaran-hanya untuk PT yang membuka seleksi mandiri<br /> <p align="center"> dengan fasilitasi bidikmisi</p>
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<!DOCTYPE HTML>
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<meta http-equiv="content-type" content="text/html" />
<meta name="author" content="mafni" />
<title>Formulir 2</title>
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<!DOCTYPE HTML>
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<meta http-equiv="content-type" content="text/html" />
<meta name="author" content="Mafni" />
<title>QUIZ</title>
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<table frame="box" align="center" cellspacing="0" cellpadding="5" style="font-family: calibri; font-size: large;">
<tr bgcolor="">
<img align="left" src="D:/BIDIK MIS.PNG" width="140" height="60" />
<th colspan="4" bgcolor=""><font size="+2">LAMPIRAN 3 : FORMULIR PENDAFTARAN<br />
PROGRAM BIDIKMISI DIKTI KEMDIKBUD 2013 <br />
(formulir diisi dengan huruf kapital)</font></th>
</tr>
<tr>
</tr>
<tr>
<td width="250">9. JUMLAH ORANG TINGGAL </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td>Orang</td>
</tr>
<tr>
<td width="200" colspan="4"><strong>IV. EKONOMI KELUARGA</strong></td>
</tr>
<tr>
<td width="250">1. PENGHASILAN AYAH/WALI </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td>rupiah</td>
</tr>
<tr>
<td width="200">2. PENGHASILAN IBU</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td>rupiah</td>
</tr>
<tr>
<td width="150" colspan="4"><strong>V. PENDIDIKAN</strong></td>
</tr>
<tr>
<td width="200">1. KODE SEKOLAH ASAL </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="300" colspan="2">Nomor Pokok Sekolah Nasional</td>
</tr>
<tr>
<td width="200">2. NAMA SEKOLAH ASAL </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="150">3. NOMOR INDUK </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="300" colspan="2">Nomor Pokok Siswa Nasional </td>
</tr>
<tr>
<td width="150">4. TAHUN LULUS</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="150">5. JURUSAN</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="300">6. URUTAN PRESTASI DI SEKOLAH</td>
<td width="500" colspan="4"></td>
<tr>
</tr>
<td width="150">a. Semester 4</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td colspan="2"></td>
<td width="200">Nilai Rapor</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<tr>
</tr>
<td width="150">a. Semester 5</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td colspan="2"></td>
<td width="150">Nilai Rapor</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<tr>
</tr>
<td width="150">a. Semester 6</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="200" colspan="2">(khusus lulusan 2012)</td>
<td width="150">Nilai Rapor</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="400">7. PRESTASI KO / EKSTRA KURIKULER TERBAIK </td>
<td width="500" colspan="4"></td>
<tr>
</tr>
<td width="150">a. Prestasi 1</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<tr>
</tr>
<td width="150">a. Prestasi 1</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="500" colspan="4"><strong>VI. PILIHAN</strong></td>
<tr>
</tr>
<td width="300">1. KODE PERGURUAN TINGGI</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<tr>
</tr>
<td width="300">2. NAMA PERGURUAN TINGGI</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<tr>
</tr>
<td width="300">3. NAMA PRODI PILIHAN 1</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td>KODE</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<tr>
</tr>
<td width="300">4. NAMA PRODI PILIHAN 2</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td>KODE</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="600" colspan="4"><strong>VII. RENCANA HIDUP DI LOKASI PENDIDIKAN YANG DITUJU APABILA DITERIMA</strong></td>
</tr>
<tr>
<td width="300">1. RENCANA TEMPAT TINGGAL </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="700" colspan="4">(1. Bersama Keluarga/Kenalan; 2. Kos/Sewa; 3. Pesantren; 4. Belum Ada)</td>
</tr>
<tr>
<td width="300">2. ADA DUKUNGAN KELUARGA </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="700" colspan="2">(1. Ya; 2. Tidak)</td>
</tr>
<tr>
<td width="300">3. TRANSPORT DARI DAERAH ASAL </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="300" colspan="">1. Pesawat terbang : <input type="text" value="" /></td>
<td width="300" colspan="">2. Kapal laut : <input type="text" value="" /></td>
<td width="300" colspan="">3. Kendaraan Darat : <input type="text" value="" /></td>
</tr>
<tr>
<td width="300">4. TRANSPORT SEHARI-HARI </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
<td width="700" colspan="3">(1.Sepeda Motor 2.Sepeda; 3.Becak; 4.Kendaraan Umum; 5.Lainnya)</td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="300" colspan="4"><strong>VII. CATATAN KHUSUS</strong></td>
</tr>
<tr>
<td width="300">KONDISI KESEHATAN </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
<td width="300">(sakit kronis, ketunaan, dsb) </td>
<td style="width: 200px;">:<input type="text" value="" /></td>
</tr>
<tr>
</body>
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