PERSYARATAN DAN TATA CARA PENDAFTARAN: 1. Warga Negara Indonesia. 2. Untuk warga Negara asing harus menunjukkan surat izin dari Ditjen Dikti Depdiknas. 3. Memiliki latar belakang pendidikan sarjana (S1) yang relevan : 4. Membayar uang pendaftaran sebesar Rp.350.000,- yang disetorkan langsung ke sekretariat pendaftaran Program Pascasarjana. 5. Photo copy Ijazah dan Transkrip Akademik yang telah dilegalisir masingmasing 1 (satu) lembar. 6. Bagi lulusan luar negeri, photo copy Ijazah dan Transkrip Akademik telah dilegalisir oleh Ditjen Dikti. 7. Menyerahkan Pas Photo Berwarna Ukuran: a. 3 × 4 sebanyak 4 lembar 8. Mengisi dan menyerahkan formulir pendaftaran ke sekretariat Program Pascasarjana Universitas Jambi paling lambat tanggal 15 Januari 2010. 9. Mengikuti tes seleksi penerimaan pada Tanggal 16 Januari 2010.
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
1. DATA PRIBADI*) 1.1. Nama Lengkap
: .............................................................................
1.2. Tempat / Tanggal Lahir
: ..............................................................................
1.3. Jenis Kelamin
: ..............................................................................
1.4. Nama Ayah
: ..............................................................................
1.5. Nama Ibu
: ..............................................................................
1.6. Agama
: ..............................................................................
1.7. Status Perkawinan
: Belum Kawin / Kawin / Janda / Duda**)
1.7. Alamat Rumah
: ..............................................................................
1.8. No. Telp/ HP
: ..............................................................................
1.9. Asal Instansi
:…………………………………………………………
1.10.Alamat Kantor
: ..............................................................................
1.11. Biaya Pendidikan
:
a. Ditanggung Sendiri b. Beasiswa dari :………………………………………………………………… (Sebutkan nama instansi pemberi beasiswa) 1.12. Program Studi yang dipilih ***) : a. Magister Manajemen
d. Magister Teknologi Pendidikan
b. Magister Ilmu Ekonomi
e. Magister Agribisnis
c. Magister Ilmu Hukum 1.13. Kelas yang dipilih ***) : a. Kelas A (Senin – Kamis) b. Kelas B (Sabtu – Minggu)
…………..,…………………….........2010
Photo Terbaru 3x4
(……………………………………...........) Nama Lengkap *) Semua data agar ditulis dengan menggunakan huruf balok/capital **) Coret yang tidak perlu ***) Contreng Program yang dipilih Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
2. RIWAYAT PENDIDIKAN Nama sekolah, tempat dan tahun mulai pendidikan sampai mendapat ijazah: 2.1. Sekolah Dasar
:…………………………………………… ……………………………………………
2.2. Sekolah Lanjutan Tingkat Pertama :…………………………………………… ……………………………………………. 2.3. Sekolah Lanjutan Tingkat Atas
:…………………………………………… …………………………………………….
2.4. Perguruan Tinggi: a. Nama Universitas
:…………………………………………… …………………………………………….
b. Fakultas
:…………………………………………… …………………………………………….
c. Jurusan/ Prodi
:…………………………………………… …………………………………………….
d. IPK
:…………………………………………… …………………………………………….
2.5. Pendidikan dan/ atau latihan lain
:…………………………………………… …………………………………………….
3. PARTISIPASI DALAM SEMINAR/LOKAKARYA Seminar, lokakarya dan/atau kegiatan ilmiah lain yang pernah diikuti (judul kegiatan, tanggal pelaksanaan dan kedudukan pelamar dalam kegiatan tersebut) 3.1 .......................................................................................................................... .......................................................................................................................... 3.2. .......................................................................................................................... ............................................................................................................................ 3.3. .......................................................................................................................... ............................................................................................................................ 3.4. .......................................................................................................................... ............................................................................................................................ 3.5. .......................................................................................................................... ............................................................................................................................
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
4. KARYA TULIS Sebutkan judul karya tulis yang pernah dibuat untuk lima tahun terakhir ! 4.1. .......................................................................................................................... ............................................................................................................................ 4.2. .......................................................................................................................... ............................................................................................................................ 4.3. .......................................................................................................................... ........................................................................................................................... 4.4. .......................................................................................................................... ........................................................................................................................... 4.5............................................................................................................................ ............................................................................................................................
5. PENELITIAN Sebutkan judul penelitian, kedudukan pelamar dalam penelitian dan tahun pelaksanaan ! 5.1. .......................................................................................................................... ............................................................................................................................ 5.2............................................................................................................................ ........................................................................................................................... 5.3............................................................................................................................ ............................................................................................................................ 5.4…........................................................................................................................ …………............................................................................................................. 5.5............................................................................................................................ ............................................................................................................................
6. KEMAMPUAN BERBAHASA ASING BAHASA
AKTIF
PASIF
KETERANGAN
INGGRIS BELANDA LAINNYA:....................................
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
7. RIWAYAT PEKERJAAN 7.1. NIP / NRP
: .........................................................................................
7.2. Pangkat / Golongan
: ....................................................................................
7.3. Pekerjaan / jabatan yang pernah dipegang (nama pekerjaan / jabatan, tempat dan tahun secara kronologis) 7.3.1. ................................................................................................................. ................................................................................................................... 7.3.2. .................................................................................................................. .................................................................................................................. 7.3.3. .................................................................................................................. .................................................................................................................. 7.3.4. .................................................................................................................. .................................................................................................................. 7.3.5. .................................................................................................................. .................................................................................................................. 7.4. Pekerjaan / jabatan terakhir 7.4.1. Nama pekerjaan / jabatan
:.............................................................
7.4.2. Nama instansi
:.............................................................
7.4.3. Alamat instansi
:.............................................................
7.4.4. Nomor telepon
: ............................................................
7.4.5. Nama / jabatan atasan langsung: ............................................................ 7.5. Jabatan dalam organisasi masyarakat / profesi: 7.5.1. .................................................................................................................. .................................................................................................................. 7.5.2. .................................................................................................................. .................................................................................................................. 7.5.3. .................................................................................................................. .................................................................................................................. 7.5.4.................................................................................................................... ................................................................................................................... 7.5.5.................................................................................................................... ....................................................................................................................
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
8. MOTIVASI DAN PERSIAPAN 8.1. Kemukakan alasan-alasan Saudara untuk mengikuti pendidikan pada Program Pascasarjana Universitas Jambi ! 8.1.1. ............................................................................................................... ............................................................................................................... ............................................................................................................... 8.1.2. ............................................................................................................... ............................................................................................................... ...............................................................................................................
8.2. Hal-hal apakah yang telah Saudara lakukan sebagai persiapan untuk mengikuti pendidikan pada Program Pascasarjana Universitas Jambi ! 8.2.1. .............................................................................................................. ............................................................................................................... ............................................................................................................... 8.2.2. ............................................................................................................... ............................................................................................................... ...............................................................................................................
9. PERNYATAAN Saya, .................................................................yang bertanda tangan di bawah ini, menyatakan bahwa: 10.1. Semua keterangan yang saya tulis dalam formulir ini adalah BENAR. 10.2. Jika saya diterima pada Program Pascasarjana Universitas Jambi ini, maka saya
akan
mentaati
semua
ketentuan
yang
berlaku
bagi
para
mahasiswanya.
..................., ...............................2010 Materai Rp. 6000,-
............................................................ (Nama lengkap dan tanda tangan)
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
NOMOR PESERTA 10
NAMA : _________________________
Alamat/No.Telp ____________________
Jambi,
M A B 0
Hanya boleh disobek oleh petugas pendaftaran
M A B 0
NOMOR PESERTA 10
NOMOR PESERTA UJIAN MASUK PROGRAM PASCASARJANA UNIVERSITAS JAMBI TAHUN AKADEMIK 2010/ 2011
NAMA PHOTO 3x4
: ..................................................................
PROGRAM STUDI : ..................................................................
Alamat/No.Tlp
: ..................................................................
TANDA TANGAN : ……………………………………
(Peserta)
____________________ (Panitia) Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
Formulir Program Pascasarjana Universitas Jambi TA 2010/2011
