Rabu, 22 April 2015

Membuat Formulir Bidikmisi

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<meta name="author" content="johan nur" />
<title>Formulir Bidikmisi</title>
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<body>
<table  align="center" cellspacing="0" cellpadding="10">
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<td rowspan="3"><img src="C:/Users/TOSHIBA/Pictures/bidikmisi.JPG" width="170" height="75" /></td>
<th width="500">LAMPIRAN 3 : FORMULIR PENDAFTARAN</th>
<td rowspan="4" style="border: solid 3px #000000; text-align: center;  " width="100"> PASFOTO <br />TERBARU <br />3X4 </td>
   
</tr>
<tr>
<th width="500">PROGRAM BIDIKMISI DIKTI KEMENDIKBUD 2013</th>
   
</tr>
<tr>
<td align="center" width="500" >(Formulir diisi dengan huruf kapital)</td>
   
</tr>
<td>&nbsp;</td>
<tr>
</tr>
</table>

<table align="center" border="0">
<tr>
<td colspan="7"><strong>I. DATA DIRI</strong></td>
</tr>
<tr>
<td ><dd>1. &nbsp;NAMA LENGKAP</dd></td>
<td colspan="6">: <input type="text" maxlength="35" name="NAMA" size="90" /></td>

</tr>
<tr>
<td><dd>2. &nbsp; JENIS KELAMIN</dd></td>
<td >: <input type="radio" value="LAKI-LAKI" name="Gender"/>Laki-Laki&nbsp;&nbsp;&nbsp;&nbsp;
<input type="radio" value="PEREMPUAN" name="Gender"/>Perempuan</td>
</tr>
<tr>
<td><dd>3. &nbsp;AGAMA</dd></td>
<td colspan="6">: <input type="radio" value="ISLAM" name="AGAMA"/>Islam&nbsp;&nbsp;&nbsp;
<input type="radio" value="RPOTESTAN" name="AGAMA"/>Protestan&nbsp;&nbsp;&nbsp;
<input type="radio" value="KATOLIK" name="AGAMA"/>Katolik&nbsp;&nbsp;&nbsp;
<input type="radio" value="HINDU" name="AGAMA"/>Hindu&nbsp;&nbsp;&nbsp;
    <input type="radio" value="BUDDHA" name="AGAMA"/>Budha&nbsp;&nbsp;&nbsp;
    <input type="radio" value="KONGHUCU" name="AGAMA"/>Konghucu</td>
</tr>
<tr>
<td><dd>4. &nbsp;KAB/KOTA LAHIR </dd></td>
<td colspan="6">: <input type="text" name="KOTA"/></td>
</tr>
<tr>
<td><dd>5. &nbsp;TANGGAL LAHIR </dd></td>
<td colspan="6">: <input type="text" name="TGL" maxlength="2"/>-
    <input type="text" name="BLN" maxlength="2"/>-
    <input type="text" name="THN" maxlength="4"/>
    Tanggal-Bulan-Tahun</td>
</tr>
<tr>
<td><dd>6. &nbsp;ALAMAT</dd></td>
<td colspan="6">: <input type="text" name="ALAMAT" maxlength="35"/></td>
</tr>
<tr>
<td><dd>7. &nbsp;KODE POS</dd></td>
<td colspan="6">: <input type="text" name="KODEPOS" maxlength="5"/></td>
</tr>
<tr>
<td><dd>8. &nbsp;TELEPON RUMAH</dd></td>
<td colspan="6">: <input type="text" name="KODETLP" maxlength="4"/>-
<input type="text" name="NOTLP" maxlength="6"/>(Kode wilayah-No telepon)</td>
</tr>
<tr>
<td><dd>9. &nbsp;HP</dd></td>
<td colspan="6">: <input type="text" name="hp" maxlength="12"/></td>
</tr>
<tr>
<td colspan="7"><strong>II. KELUARGA</strong></td>
</tr>
<tr>
<td><dd>1. &nbsp;NAMA AYAH/WALI</dd></td>
<td colspan="6">: <input type="text" name="AYAH"/></td>
</tr>
<tr>
<td><dd>2. &nbsp;PEKERJAAN AYAH/WALI</dd></td>
<td colspan="6">: <input type="radio" value="PNS" name="PEKERJAAN"/>PNS&nbsp;&nbsp;&nbsp;
    <input type="radio" value="Peg. SWASTA" name="PEKERJAAN"/>Peg. SWASTA&nbsp;&nbsp;&nbsp;
<input type="radio" value="WIRAUSAHA" name="PEKERJAAN"/>WIRAUSAHA&nbsp;&nbsp;&nbsp;
<input type="radio" value="TNI/POLRI" name="PEKERJAAN"/>TNI/POLRI&nbsp;&nbsp;&nbsp;
    <input type="radio" value="NELAYAN" name="PEKERJAAN"/>NELAYAN&nbsp;&nbsp;&nbsp;
    <input type="radio" value="LAINNYA" name="PEKERJAAN"/>LAINNYA &nbsp;
        <input type="text" name="PEKERJAAN"/></td>
</tr>
<tr>
<td><dd>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;BEKERJA SEBAGAI</dd></td>
<td colspan="6">: <input type="text" name="PEKERJAAN1"/></td>
</tr>
<tr>
<td><dd>3. &nbsp;NAMA IBU</dd></td>
<td colspan="6">: <input type="text" name="IBU"/></td>
</tr>
<tr>
<td><dd>4. &nbsp;PEKERJAAN AYAH/WALI</dd></td>
<td colspan="6"><input type="radio" value="PNS" name="PEKERJAAN"/>PNS&nbsp;&nbsp;&nbsp;
<input type="radio" value="Peg. SWASTA" name="PEKERJAAN"/>Peg. SWASTA&nbsp;&nbsp;&nbsp;
<input type="radio" value="WIRAUSAHA" name="PEKERJAAN"/>WIRAUSAHA&nbsp;&nbsp;&nbsp;
<input type="radio" value="TNI/POLRI" name="PEKERJAAN"/>TNI/POLRI&nbsp;&nbsp;&nbsp;
    <input type="radio" value="NELAYAN" name="PEKERJAAN"/>NELAYAN&nbsp;&nbsp;&nbsp;
    <input type="radio" value="LAINNYA" name="PEKERJAAN"/>LAINNYA &nbsp;
        <input type="text" name="PEKERJAAN"/></td>
</tr>
<tr>
<td><dd>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;BEKERJA SEBAGAI</dd></td>
<td colspan="6">: <input type="text" name="PEKERJAAN1"/></td>
</tr>
<tr>
<td><dd>5. &nbsp;JUMLAH TANGGUNGGAN</dd></td>
<td colspan="6">: <input type="text" name="TANGGUNGAN" maxlength="2"/> ORANG</td>
</tr>
<tr>
<td><dd>6. &nbsp;HP ORANG TUA</dd></td>
<td colspan="6">: <input type="text" name="hp" maxlength="12"/></td>
</tr>
<tr>
<td><dd>7. &nbsp;STATUS ORANG TUA</dd></td>
    <td colspan="6"> : AYAH&nbsp; <input type="text" name="ayah" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    IBU&nbsp; <input type="text" name="ibu" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
1. &nbsp;KANDUNG&nbsp;&nbsp;
    2. &nbsp;TIRI&nbsp;&nbsp;
    3. &nbsp;ANGKAT&nbsp;&nbsp;
    4. &nbsp;LAINNYA&nbsp;&nbsp;
</td>
</tr>
<tr>
<td><dd>8. &nbsp;PENDIDIKAN ORANG TUA</dd></td>
    <td colspan="6"> : AYAH&nbsp; <input type="text" name="pendidikan ortu" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    IBU&nbsp; <input type="text" name="ibu" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
1. &nbsp;SD/MI&nbsp;&nbsp;
    2. &nbsp;SMP/MTS&nbsp;&nbsp;
    3. &nbsp;SMA/MA&nbsp;&nbsp;
    4. &nbsp;D2/D3&nbsp;&nbsp;
    5. &nbsp;S1/D4&nbsp;&nbsp;
</tr>
<tr>
<td><dd>9. &nbsp;ORANG TUA KANDUNG</dd></td>
    <td colspan="6">: AYAH&nbsp; <input type="text" name="ayah" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    IBU&nbsp; <input type="text" name="ibu" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
1. &nbsp;MASIH HIDUP&nbsp;&nbsp;
    2. &nbsp;SUDAH WAFAT&nbsp;&nbsp;
    3. &nbsp;LAINNYA&nbsp;&nbsp;
</tr>
<tr>
<td colspan="7"><strong>III. RUMAH TINGGAL KELUARGA</strong></td>
</tr>
<tr>
<td><dd>1. &nbsp;KEPEMILIKAN</dd></td>
    <td colspan="6">: <input type="text" name="pemilik rmah" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    (1. &nbsp;SENDIRI;&nbsp;&nbsp;
    2. &nbsp;SEWA TAHUNAN;&nbsp;&nbsp;
    3. &nbsp;SEWA BULANAN;&nbsp;&nbsp;
    4. &nbsp;MENUMPANG;&nbsp;&nbsp;
    5. &nbsp;TIDAK MEMILIKI;&nbsp;&nbsp;
    (4)&(5) LANGSUNG IV)</td>
</tr>
<tr>
    <td><dd>2. &nbsp;TAHUN PEROLEHAN</dd></td>
    <td colspan="6">: <input type="text" name="thn" maxlength="4" size="10"/></td>
</tr>  
<tr>
    <td><dd>3. &nbsp;SUMBER LISTRIK</dd></td>
    <td colspan="6">: <input type="text" name="listrik" maxlength="1" size="10"/>&nbsp;&nbsp;&nbsp;
    <input type="text" name="ayah" maxlength="1" size="20"/>&nbsp;&nbsp;&nbsp;
    (1. &nbsp;PLN;&nbsp;&nbsp;
    2. &nbsp;GENSET/MANDIRI;&nbsp;&nbsp;
    3. &nbsp;TENAGA SURYA;&nbsp;&nbsp;
    4. &nbsp;PLN & GENSET ;&nbsp;&nbsp;
    5. &nbsp;TIDAK ADA; )&nbsp;&nbsp;
    </td>
</tr>  
<tr>
<td><dd>4. &nbsp;LUAS TANAH</dd></td>
    <td colspan="6">: <input type="text" name="tanah" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    (1. &nbsp; > 200  M <sup>2</sup> ;&nbsp;&nbsp;
    2. &nbsp; 100-200  M <sup>2</sup> ;&nbsp;&nbsp;
    3. &nbsp; 50-99  M <sup>2</sup> ;&nbsp;&nbsp;
    4. &nbsp; < 25-50 M <sup>2</sup> ;&nbsp;&nbsp;)</td>
</tr>
<tr>
<td><dd>5. &nbsp;LUAS BANGUNAN</dd></td>
    <td colspan="6">: <input type="text" name="bangunan" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    (1. &nbsp; > 200  M <sup>2</sup> ;&nbsp;&nbsp;
    2. &nbsp; 100-200  M <sup>2</sup> ;&nbsp;&nbsp;
    3. &nbsp; 50-99  M <sup>2</sup> ;&nbsp;&nbsp;
    4. &nbsp; < 25-50 M <sup>2</sup> ;&nbsp;&nbsp;)</td>
</tr>
<tr>
<td><dd>6. &nbsp;MANDI CUCI KAKUS</dd></td>
    <td colspan="6">: <input type="text" name="mck" maxlength="1" size="2"/> &nbsp;&nbsp;&nbsp;
    (1. &nbsp;KEPEMILIKAN SENDIRI DIDALAM;&nbsp;&nbsp;
    2. &nbsp;KEPEMILIKAN SENDIRI DILUAR;&nbsp;&nbsp;
    3. &nbsp;BERBAGI PAKAI; )&nbsp;&nbsp;</td>
</tr>
<tr>
<td><dd>7. &nbsp;SUMBER AIR</dd></td>
    <td colspan="6">: <input type="text" name="air" maxlength="1" size="2"/>KEMASAN &nbsp;&nbsp;&nbsp;
    &nbsp; <input type="text" name="ayah" maxlength="1" size="2"/>PDAM &nbsp;&nbsp;&nbsp;
    &nbsp; <input type="text" name="ayah" maxlength="1" size="2"/>SUMUR &nbsp;&nbsp;&nbsp;
    &nbsp; <input type="text" name="ayah" maxlength="1" size="2"/>SUNGAI/MATA AIR /GUNUNG&nbsp;&nbsp;&nbsp;
    </td>
</tr>
<tr>
<td><dd>7. &nbsp;JARAK DARI PUSAT KOTA / KAB</dd></td>
    <td colspan="6">: <input type="text" name="jarak" maxlength="1" size="2"/>KM
    </td>
</tr>
<tr>
<td><dd>9. &nbsp;JUMLAH ORANG TINGGAL</dd></td>
    <td colspan="6">: <input type="text" name="jumlah orang" maxlength="2" size="2"/>ORANG
    </td>
</tr>  
<tr>
<td colspan="7"><strong>IV. EKONOMI KELUARGA</strong></td>
</tr>
<tr>
<td ><dd>1. &nbsp;PENGHASILN AYAH/WALI</dd></td>
<td colspan="6">: <input type="text" maxlength="35" name="NAMA"  /></td>

</tr>
<tr>
<td><dd>2. &nbsp; PENGHASILAN IBU</dd></td>
<td colspan="6">: <input type="text" maxlength="35" name="NAMA" /></td>
</tr>
<tr>
<td colspan="7"><strong>V. PENDIDIKAN</strong></td>
</tr>
<tr>
<td><dd>1. &nbsp; KODE SEKOLAH ASASL</dd></td>
<td colspan="6">: <input type="text" maxlength="35" name="NAMA" /> Nomor Pokok Sekolah Nasional</td>
</tr>
<tr>
<td><dd>2. &nbsp; NAMA SEKOLAH</dd></td>
<td colspan="6">: <input type="text" maxlength="35" name="NAMA" /> </td>
</tr>
<tr>
<td><dd>3. &nbsp; NOMOR INDUK</dd></td>
<td colspan="6">: <input type="text" maxlength="8" name="NAMA" /> Nomor Induk Siswa Nasional </td>
</tr>
<tr>
<td><dd>4. &nbsp; TAHUN LULUS</dd></td>
<td colspan="6">: <input type="text" maxlength="4" name="NAMA" /> </td>
</tr>
<tr>
<td><dd>5. &nbsp; JURUSAN</dd></td>
<td colspan="6">: <input type="text" maxlength="8" name="NAMA" /> </td>
</tr>
<tr>
<tr>
    <td ><dd>6. URUTAN PRESTASI DI SEKOLAH</td>
    <td colspan="6"></td>
<tr>
</tr>
    <td ><dd><dd>a. Semester 4</td>
    <td colspan="6">:<input type="text" value="" maxlength="2" />
    Nilai Rapor:<input type="text" value="" maxlength="2" /></td>
<tr>
</tr>
    <td ><dd><dd>b. Semester 5</td>
    <td colspan="6">:<input type="text" value="" maxlength="2" />
    Nilai Rapor:<input type="text" value="" maxlength="2" /></td>
<tr>
</tr>
    <td ><dd><dd>c. Semester 6</td>
    <td colspan="6">:<input type="text" value="" maxlength="2" />
    Nilai Rapor:<input type="text" value="" maxlength="2" /></td>
<tr>
<tr>
    <td ><dd>7. PRESTASI KO / EKSTRA KURIKULER TERBAIK </td>
    <td colspan="6"></td>
<tr>
</tr>
    <td ><dd><dd>a. Prestasi 1</td>
    <td colspan="6">:<input type="text" value="" maxlength="20"/></td>
<tr>
</tr>
    <td ><dd><dd>b. Prestasi 1</td>
    <td colspan="6">:<input type="text" value="" maxlength="20"/></td>
</tr>
<tr>
    <td  colspan="7"><strong>VI. PILIHAN</strong></td>
<tr>
</tr>
    <td ><dd>1. KODE PERGURUAN TINGGI</td>
    <td colspan="6">:<input type="text" value="" maxlength="6"/></td>
<tr>
</tr>
    <td ><dd>2. NAMA PERGURUAN TINGGI</td>
    <td colspan="6">:<input type="text" value="" maxlength="20"/></td>
<tr>
</tr>
    <td ><dd>3. NAMA PRODI PILIHAN 1</td>
    <td colspan="6">:<input type="text" value="" maxlength="20" />
    KODE
    :<input type="text" value="" /></td>
<tr>
</tr>
    <td ><dd>4. NAMA PRODI PILIHAN 2</td>
    <td colspan="6"">:<input type="text" value="" />
    KODE
    :<input type="text" value="" /></td>
</tr>
<tr>
    <td  colspan="7"><strong>VII. RENCANA HIDUP DI LOKASI PENDIDIKAN YANG DITUJU APABILA DITERIMA</strong></td>
</tr>
<tr>
    <td ><dd>1. RENCANA TEMPAT TINGGAL </td>
    <td colspan="6">:<input type="text" value="" />
    (1. Bersama Keluarga/Kenalan; 2. Kos/Sewa; 3. Pesantren; 4. Belum Ada)</td>
</tr>
<tr>
    <td ><dd>2. ADA DUKUNGAN KELUARGA </td>
    <td>:<input type="text" value="" />
    (1. Ya; 2. Tidak)</td>
</tr>
<tr>
    <td ><dd>3. TRANSPORT DARI DAERAH ASAL </td>
    <td colspan="6">:<input type="text" value="" />
    1. Pesawat terbang : <input type="text" value="" />
    2. Kapal laut : <input type="text" value="" />
    3. Kendaraan Darat : <input type="text" value="" /></td>
</tr>
<tr>
    <td ><dd>4. TRANSPORT SEHARI-HARI </td>
    <td colspan="6">:<input type="text" value="" />
    (1.Sepeda Motor 2.Sepeda; 3.Becak; 4.Kendaraan Umum; 5.Lainnya)
    :<input type="text" value="" /></td>  
</tr>
<tr>
    <td colspan="7"><strong>VIII. CATATAN KHUSUS</strong></td>
</tr>
<tr>
    <td >KONDISI KESEHATAN </td>
    <td colspan="6">:<input type="text" value="" /></td>
</tr>
<tr>
    <td >(sakit kronis, ketunaan, dsb) </td>
    <td colspan="6">:<input type="text" value="" /></td>
</tr>
<tr>
<td align="center" colspan="3"> Dengan Ini Saya Menyatakan Dengan penuh Kesadaran untuk taat dan patuh terhadap ketentuan umum dan<br />khusus Bidikmisi, Menjunjung tinggi kehormatan pribadi, keluarga, almamater dan asal sekolah dengan mengisi<br />segala informasi sebenar-benarnya. Saya bersedia diknai sanksi apabila melanggar ketentuan dan memberikan<br />informasi yang tidak benar. </td>
</tr>
<tr>
<td colspan="3" align="right">................................................  ................................................</td>
</tr>
<td><br /></td>
</tr>
<tr>
<td colspan="3" align="right">(................................................  ................................................)</td>
</tr>
<tr>
<td colspan="3" align="right">Nama Lengkap Pendaftar&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
</tr>
</table>


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