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”

Pas Foto

3x4

Pas Foto

3x4

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”