PROGRAM PASCASARJANA ILMU MANAJEMEN FAKULTAS EKONOMI UNIVERSITAS MALIKUSSALEH FORMULIR PENDAFTARAN MAHASISWA (APPLICATION FOR GRADUATE ADMISSION)
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BIODATA MAHASISWA (Personal Details) Nama Lengkap (Full Name)
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Tempat/Tgl Lahir (Place/Date of Birth)
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Jenis Kelamin (Gender)
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Agama (Religion)
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Suku Bangsa (Race)
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Warganegara (Nationality)
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Status Perkawinan (Marital Status)
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No. Kartu (KTP) (Identity Card No.)
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No. Pasport (Pasport No.)
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Alamat (Address)
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No. Tel (Tel. No.)
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No. Fak (Fax. No.)
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HP (Mobile)
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E-mail (E-mail)
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[
] Laki-laki (Male)
[
] Perempuan (Female)
ORANG YANG DAPAT DIHUBUNGI SAAT DARURAT / Person to be notified in case of emergency Nama (Name)
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Hubungan (Relationship)
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Alamat (Address)
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HP (Mobile)
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* Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
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LATAR BELAKANG AKADEMIK (Academic Background) Nama Sekolah dan Alamat Jurusan (Name and Address of College) (Departement)
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Ijazah yang diperoleh (Degree Obtained)
Tempat (Place)
Lamanya (Time)
Tahun (Year)
RIWAYAT PEKERJAAN/PENGALAMAN (Employment Details/Experience) Nama Jabatan (Name of Positions)
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Tanggal Ijazah (Date of Graduation)
PENDIDIKAN TAMBAHAN (Academic Additional) Kursus/Pelatihan (Course/Trainning)
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Tahun Masuk (Year of Entry)
Nama dan Alamat (Employer’s name and address)
Rentang Waktu (From - To)
Keterangan (Description)
KEMAMPUAN BAHASA dan TPA (Language and GMAT Proficiency) Kemampuan (Proficiency)
TOEFL IELTS TPA
* Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
Nama Lembaga/Ujian (Name of Examination/Test)
Nilai/Skor (Grade)
Tahun Lulus (Year Passed)
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PUBLIKASI ILMIAH (Professional Publications) Buku/Jurnal (Title of Book/Journal)
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Tahun Diterbitkan (Year of Publication)
Nama dan Tempat Penerbitan (Name and Location of Publication)
BANTUAN KEUANGAN (Financial Support) Sebutkan sumber bantuan keuangan anda (Please indicate your source of financial support) Dibiayai penuh oleh Negara / Beasiswa (Fully sponsored by government) Dibiayai penuh oleh Perusahaan / Yayasan (Fully sponsored by employer) Biaya sendiri/keluarga (Supported by myself / my family) Nama dan alamat penanggungjawab atau organisasi yang akan membayar biaya Anda (Name and address of person and organization paying your fees) __________________________________________________________________________________ __________________________________________________________________________________
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REKOMENDASI AKADEMIK [dua (2) orang] (Academic Referees) [two (2) people] Pemberi rekomendasi akademik adalah mereka yang mengenali calin dari bidang akademik (contoh : Dekan, Dosen, Pimpinan) dan sebaiknya bukan kawan atau saudara sendiri. (The academic referees must comprise of those who know the applicant in terms of his/her academic performance [e.g. : Dean, Lecturer, Employer] and should not have any personal acquaintances or relatives) 1) Nama (Name)
: _____________________________
2) Nama (Name)
: ______________________________
Alamat : _____________________________ (Address) _____________________________
Alamat : ______________________________ (Address) ______________________________
_____________________________
______________________________
No. HP. : _____________________________ (Mobile)
No. HP. (Mobile)
Jabatan saat ini : _______________________ (Official Postion)
Jabatan saat ini : ________________________ (Official Postion)
* Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
: ______________________________
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BIDANG KONSENTRASI (My Fields of Interest) [
] MANAJEMEN PEMASARAN / Marketing Management
[
] MANAJEMEN STRATEGIK / Strategic Management
[
] MANAJEMEN KEUANGAN / Financial Management
[
] MANAJEMEN SUMBERDAYA MANUSIA / Human Resources Management
[
] MANAJEMEN KEUANGAN DAERAH / Financial Local Government Management
PERNYATAAN (Declaration) Dengan ini saya nyatakan bahwa semua keterangan di atas dan dokumen yang saya berikan adalah benar dan lengkap. Universitas Malikussaleh Lhokseumawe berhak menolak permohonan ini sekiranya keterangan tersebut didapati palsu dan/atau tidak lengkap. (I hereby certify that the above information and documents enclosed are true and complete. University of Malikussaleh Lgokseumawe reserves the right to reject this application if the information given is false and/or incomplete).
_________________________ Tandatangan Pemohon (Applicant’s Signature)
* Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
__________________________ Tanggal (Date)
SURAT REKOMENDASI (Referee’s Report) Surat reomendasi ini hendaklah diisi oleh pemberi rekomendasi sendiri dan diberikan kepada pemohon untuk dihantar bersama dengan formulir permohonan. (This report must be sealed by the referees and forward the envelope to the applicant to be submitted together with the application form) BAHAGIAN A : TENTANG CALON (Part A : The applicant) Nama Calon (Name)
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______________________________________________________________
Program Magister (Programme of Studies)
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______________________________________________________________
Alamat (Address)
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______________________________________________________________
BAHAGIAN B : PEMBERI REKOMENSASI (Part B : To be Completed by the referee) Nama (Name)
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______________________________________________________________
Jabatan Saat ini (Official Position)
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______________________________________________________________
Alamat (Address)
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______________________________________________________________
No. Tel (Tel. No.)
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______________________________________________________________
No. Fak (Fax. No.)
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______________________________________________________________
HP (Mobile)
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______________________________________________________________
E-mail (E-mail)
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______________________________________________________________
BAHAGIAN C : LAPORAN PEMBERI REKOMENDASI (Part C : Referee’s Report) a) Berapa lamakah Anda mengenali Calon? ……………..Tahun (How long have you known the applicant? No. of years) b) Bagaimana Anda mengenali Pemohon? (How do you know the applicant?) .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. c) Dalam kapasitas hubungan apa Anda mengenal Calon? (What is your relationship to the applicant?) .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. d) Adakah Anda percaya Calon akan mampu untuk menyelesaikan pendidikannya? (Do you believe that the applicant is prepared for graduate?) [ ] Ya (Yes) [ ] Tidak (No) e) Bagaimanakah Anda menilai Calon terhadap hal-hal sebagai berikut? (Tandakan ) (How do you rate the applicant on each of the following?) (Please tick * Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
Cemerlang (Excellent)
Amat Baik (Very Good)
Baik (Good)
Sederhana (Average)
1) Kecakapan intelek (Intellectual ability) 2) Kematangan dan kestabilan emosi (Maturity and emotional ) 3) Motivasi (Motivation) 4) Pengetahuan Umum (General Knowledge) 5) Inisiatif (Initiative) 6) Kerjasama (Ability to cooperate) 7) Tanggungjawab (Responsibility)
PEMBERI REKOMENDASI (Recommendation)
__________________________ Tandatangan/Nama Jelas (Referee’s Signature)
* Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
___________________________ Tanggal (Date)
Lemah (Poor)
PERSYARATAN PESERTA Nama Calon (Name)
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No. Test (Test No.)
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Angkatan
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Kelas (Class)
: Khusus / A / B
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LENGKAP
BELUM LENGKAP
KETERANGAN
Foto Copy Ijazah (legalisir) • PTN (S-1) • PTS (S-1) • Luar Negeri (S-1)
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Foto Copy Transkrip Nilai (legalisir) • PTN (S-1) • PTS (S-1) • Luar Negeri (S-1)
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SK Rektor/Ketua Yayasan
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Pas Photo Warna Ukuran • 4 x 6 cm = 2 lembar • 3 x 4 cm = 6 lembar • 2 x 2,5 cm = 4 lembar
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FORMULIR PENDAFTARAN
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2 BUAH SURAT REKOMENDASI
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NILAI • TPA • TOEFL
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SURAT KESEHATAN
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PERSYARATAN
Lhokseumawe, ………………………………2014 Panitia Penerimaan Mahasiswa Baru,
………………………………………………………….. NIP.
* Catatan : Beri tandakan ( X ) Note : Please tick ( X ) whichever applicable
