KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI UNIVERSITAS NEGERI MALANG (UM) HIMPUNAN MAHASISWA JURUSAN FISIKA FMIPA Jalan Semarang 5, Malang 65145 Telepon/Fax: 0341-562180, 551312 Pesawat 265 Laman: www.um.ac.id No.: ....-...........**/HMJFIS/PAN.OLIMP/2015 Nama lengkap 1 : ........................................................................... ........................................................L/P* Tempat, tgl. lahir : ........................................................................... ................................................................ Asal sekolah : ........................................................................... ................................................................ Delegasi : .......................................................... ............................................................................... .. Rayon pilihan : ........................................................................... ................................................................ Kontak : .......................................................... ............................................................................... .. Nama lengkap 2 : ........................................................................... ........................................................L/P* Tempat, tgl. lahir : ........................................................................... ................................................................ Asal sekolah : ........................................................................... ................................................................ “Fisika Berkarya Untuk Indonesia”
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KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGIUNIVERSITAS NEGERI MALANG (UM)
HIMPUNAN MAHASISWA JURUSAN FISIKA FMIPAJalan Semarang 5, Malang 65145
Telepon/Fax: 0341-562180, 551312 Pesawat 265Laman: www.um.ac.id
No.: ....-...........**/HMJFIS/PAN.OLIMP/2015
Nama lengkap 1 :...................................................................................................................................L/P*
Tempat, tgl. lahir :...........................................................................................................................................
Asal sekolah :...........................................................................................................................................
Delegasi : ...........................................................................................................................................Rayon pilihan :
...........................................................................................................................................Kontak : ...........................................................................................................................................
Nama lengkap 2 :...................................................................................................................................L/P*
Tempat, tgl. lahir :...........................................................................................................................................
Asal sekolah :...........................................................................................................................................
Delegasi : ...........................................................................................................................................Rayon pilihan :
...........................................................................................................................................Kontak : ...........................................................................................................................................
................., ..............................2015
Panitia Olimpiade Fisika Nasional Tingkat SMP dan SMA 2015, Pendaftar,
_________________________________ _________________ ________________
“Fisika Berkarya Untuk Indonesia”
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KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGIUNIVERSITAS NEGERI MALANG (UM)
HIMPUNAN MAHASISWA JURUSAN FISIKA FMIPAJalan Semarang 5, Malang 65145
Telepon/Fax: 0341-562180, 551312 Pesawat 265Laman: www.um.ac.id
Keterangan:*) Coret yang tidak perlu**) Diisi oleh panitia rayonFormulir ini bisa digandakan sesuai dengan kebutuhan
“Fisika Berkarya Untuk Indonesia”
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