Formulir Pendaftaran ITS Gasal 20152016

7/21/2019 Formulir Pendaftaran ITS Gasal 20152016

1/16

PROGRAM MAGISTER DAN

PROGRAM DOKTORSEMESTER GASAL TA.

2015/2016

Formulir

Pe!"#$"r"

N"m"

Pro%r"m

Pro%r"mS$u!i

&i!"%Ke"'li"

Kel"( )K'u(u(MMT*

Nomor Te(

+

+

+

+

+

+

,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

,,,,,,,,,,

MAGISTER / DOKTOR )-ore$ "% $i!"erlu*

,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

PROFESIONAL / EKSEKTIF )-ore$"% $i!" erlu*

,,,,,,,,,,,,,,,,,,,,,, )!ii(i e$u%"(e!"#$"r"*

Pro%r"mP"(-"("r""I($i$u$

Teolo%i

Seulu'

Noem3er 4

Sur"3""

Kampus ITSSukoliloSurabaya, 60111

Telp :(031) 5992526,5994251 ex!


2/16

"ormulir ya#$ %arus &iisi

"l"m

"2

Untuk Peserta Program Magister (S2):

NoFormulir yang harus

diisiHalaman

Tipe PelamarPelamarBeasisa

Pelamar NonBeasisa

Pelamar!er"asama

1. Data pelamar 4 s/d 6

2. Formulir A 7

3. Formulir B 8

4. Formulir C 9

5. Formulir D 10

6. Formulir E 11 s/d 12

7. Formulir F 13

8. Formulir 14

9. !ampira" 15

Untuk Peserta Program #oktor (S$):

NoFormulir yang harus

diisiHalaman

Tipe PelamarPelamarBeasisa

Pelamar NonBeasisa

Pelamar!er"asama

1. Data pelamar 4 s/d 6 2. Formulir A 7

3. Formulir B 8

4. Formulir C 9

5. Formulir D 10

6. Formulir E 11 s/d 12

7. Formulir F 13

8. Formulir 14

9. Formulir # 15

10. !ampira" 15

%n&ormasi tam'ahan untuk pemohon Beasisa BPP #N #%!T% (S2 S$):a. Formulir B dita"data"$a"i ole% &impi"a" &er$urua" 'i"$$i da"

disa%(a"/distempel. )%usus pelamar *a"$ +erasal dari )opertis/&',- ormulirterse+ut %arus dire(ome"dasi ole% )opertis ila*a% asal &er$urua" 'i"$$ipelamar.

+. )%usus pelamar *a"$ +erasal dari )opertis/&', %arus mempu"*ai a+ata"a(ademi( mi"imal Asiste" A%li de"$a" a"$(a (redit mi"imal 100 *a"$ di+u(ti(a"de"$a" oto(opi ,) a+ata" Fu"$sio"al Dose" !ampir(a" di lem+ar !ampira".


3/16

I#'ormasi a# ersyaraa#e#a'ara#

"l"m

"

1. e"$isi ormulir pe"datara" +eserta lampira""*a de"$a" le"$(ap da" elas.

2. e"$umpul(a" oto ter+aru- u(ura" 46 %itam puti%/ar"a se+a"*a( 2 lem+arditempel di ormulir pe"datara".

3. em+a*ar +ia*a pe"datara" uia" masu( p. 500.000- ,2 da" p. 500.000- ,3

pe"datara" seara la"$su"$ di Teller seluru% Ba"( B:;- de"$a"me"*e+ut(a" di%adapa" teller te"ta"$ pem+a*ara" +ia*a pe"datara"&ro$ram &asasara"a ;',.

4. Formulir da" lampira""*a *a"$ suda% diisi le"$(ap dioto(opi 1 satu (ali.

5. Formulir asli +eserta oto(opi"*a di(irim(a" melalui pos/disampai(a" se"diri(e alamat>>>>>>>>>>>>>>>>>>>>>>>>

:?: BEA,;,A ,e"diri/;"sta"si @

)EA,AA ,e+ut(a" < >>>>>>>>>>>>>>>>>>>>>>>>

4. &er"a% me"$i(uti uia" masu( &ro$ram &asasara"a ;',< per"a%/+elum @

i(a per"a%- (apa" < >>>>>>>>>>>>>>>>>>- &ro$ram ,tudi < >>>>>>>>>>>>>>>>>>>>>>>

B5 #/T/ P6%B/#% (isi yang sesuai)

1. :ama !e"$(ap < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

2. :;&/:;& < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

3. 'empat !a%ir < >>>>>>>>>>>>>>>>>>>>>>>- '$l. !a%ir< >>>>>>>>>>>>>>>>>>>>>

4. Alamat ,urat < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

)ota < >>>>>>>>>>>>>>>>>>>>>>>- )ode &os< >>>>>>>>>>>>>>>>>>>>>

'elepo" < >>>>>>>>>>>>>>>>>>>>>>>- #&< >>>>>>>>>>>>>>>>>>>>>>>>>>>

Email < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

5. A$ama < >>>>>>>>>>>>>>>>>>>>>>>- olo"$a" dara%< >>>>>>>>>>>>>>>

6. e"is )elami" < &ria/a"ita @

7. ,tatus &er(ai"a" < )ai"/Belum (ai" @

=5 P!6//N ('agi yang sudah 'eker"a)

1. :ama ;"sta"si < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>2. Alamat < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

)ota < >>>>>>>>>>>>>>>>>>>>>>- )ode &os < >>>>>>>>>>>>>>>>>>>

'elepo" < >>>>>>>>>>>>>>>>>>>>>>

3. ,tatus ;"sta"si < &emeri"ta%/,asta/B=:/&':/&', @

4. 'a%u" mulai +e(era < >>>>>>>>>>>>>>>>>>>>>>

@ oret *a"$ tida( perlu


5/16

"l"m"5

&aa *alo# +aasis-a

#5 >/T/6 PN#%#%!/N ; !8%/T/N /!/#M%!

D.1 Pendidikan Formal S?. (untuk pelamar program Magister)

1. :ama da" 'empat &er$urua" 'i"$$i ,1< >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

2. urusa"/Fa(ultas ,1 < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

3. 'a%u" asu( < >>>>>>>>>>>>>>>>> - 'a%u" ,elesai < >>>>>>>>>>>>>>>>>>>>

,elesai =ia" :e$ara- 'a%u" < >>>>>>>>>>>>>>>>>>>>>>>> i(a ada

4. ;&) ,1 < >>>>>>>>>>>>>

;&) =ia" :e$ara < >>>>>>>>>>>>> i(a ada

5. elar < ,ara"a >>>>>>>>>>>>>>>>>>>>>

D.2 Pendidikan Formal S?2 (untuk pelamar program #oktor)

1. :ama da" 'empat &er$urua" 'i"$$i ,2 < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

2. urusa"/Bida"$ ,tudi ,2 < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

3. 'a%u" asu( < >>>>>>>>>>>>>>>>> - 'a%u" ,elesai < >>>>>>>>>>>>>>>>>>>>>

4. ;&) ,2 < >>>>>>>>>>>>>>>>>

5. elar ,2 < >>>>>>>>>>>>>>>>>

D.3 Pendidikan Tam'ahan;Penataran;!ursus %lmiah

!ampir(a" sali"a" ,ertii(at di lem+ar >ampiran

No5 Nama dan Tempat Bidang Tahun>ama

Pendidikan

D.4 Penguasaan Bahasa /sing

1. Ba%asa ;"$$ris < Bai(/,eda"$/)ura"$ @

2. >>>>>>>>>>>>>>>> < Bai(/,eda"$/)ura"$ @

3. >>>>>>>>>>>>>>>> < Bai(/,eda"$/)ura"$ @

@ oret *a"$ tida( perlu

:ilai '?EF! / tes B%s. ;"$$ris lai""*a>>>>>>

(Lampirkan nilai TOEFL / hasil tes Bahasa Inggris lainnyadi lembar Lampiran)


6/16

"l"m"10

&aa *alo# +aasis-aD.5 !egiatan >ain 9ang Pernah /nda >akukan

1. Penelitian- a"tum(a" >>>>>- u"tu( pe"didi(a" ti"$(at,ara"a/a$ister/Do(tor di ="iersitas/;"stitut >>>>>>>>>>>>>>>>>>>>>>>

[ ],a*a +elum per"a% memperole% +ia*a pe"didi(a" dari Dire(torat e"deral&e"didi(a" 'i"$$i.

,a*a +ersedia meme"u%i (eai+a" da" me"a"data"$a"i surat pera"ia"+er(e"aa" de"$a" +ia*a pe"didi(a" terse+ut.

>>>>>>>>>>>>- >>>>>>>>>>>>>>> 20>>>a"$ me"*ata(a"-

>>>>>>>>>>>>>>>>>>>>>>>>>>>>


8/16

"ormulir . (u#uk emoo# .

"l"m"10

&E:A'AA: &E:=A,A:E:;)='; &?A &A,CA,AA:A

DE:A: B;AA D;E)'?A' E:DEA! &E:D;D;)A: ';:;

Dalam ra"$(a me"i"$(at(a" (i"era proses +elaarme"$aar da" (ualitas dose" serta

pe"$em+a"$a" +ida"$ ilmu- sa*a me"u$as(a" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

Dose" 'etap &er$urua" 'i"$$i :e$eri/,asta pada A(ad/&olte(/,'/;"st/="i.>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

:;&. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>- i(a +erstatus pe$aai "e$eri sipil

:;& a*asa" >>>>>>>>>>>>>>>>>>>>>>>>>- de"$a" :omor ,urat )eputusa" a*asa" ,)

terlampir < >>>>>>>>>>>>>>>>>>>>>>>>> pe$aai i(a +erstatus dose" tetap *a*asa"

:;D:. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>- +a$i *a"$ suda% memili(i :;D:

u"tu( me"$i(uti pe"didi(a" a$ister/Do(tor &ro$ram ,tudi < >>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> di ;"stitut 'e("olo$i ,epulu% :opem+er.

="tu( me"ami" (ela"ara" tu$as- selama me"$i(uti pe"didi(a" di &ro$ram &asasara"a

*+s di+e+as(a" dari tu$as ruti" (a"tor atau tu$as a(ademi( da" admi"istrati.

>>>>>>>>>>>- >>>>>>>>>>>>>> 20>>>

Dir/)et/e(torA(ad/&olte(/,'/;"st./="i.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>> :;&/:;&.


9/16

"ormulir * (u#uk emoo# .

"l"m"10

;AA' &E)EAA:

.5 Mata kuliah yang diasuh pada aktu sekarang< >>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

e"a+at a+ata" stru(tural )etua !a+./urusa" < a/'ida( @

a+ata" u"$sio"al < Asiste"/!e(tor uda/!e(tor/!e(tor (epala @

Alamat (a"tor < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>-'elp. >>>>>>>>>>>>>>>>>>>>>>>>>>>>

25 #a&tar Mata !uliah yang diasuh+ semester+ tahun

Mata !uliah Semester Tahun

$5 a'atan Struktural Perguruan Tinggi :

a'atan Struktural /ntara Tahun

e(tor/)etua/Dire(tur

&em+a"tu e(tor/)etua/Dire(tur

De(a"/Dire(tur

&em+a"tu De(a"/Asiste" Dire(tur

)etua urusa"

,e(retaris urusa"

)etua !em+a$a/&usat

>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>


10/16

"ormulir & (u#uk pelamar e#$a#

"l"m"10

&E:A'AA: &E:=A,A:

E:;)='; &?A &A,CA,AA:A

DE:A: B;AA ;:,'A:,;

Dalam ra"$(a me"i"$(at(a" (i"era sta/(ar*aa"/dose" serta pe"$em+a"$a" +ida"$

ilmu- sa*a me"u$as(a" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

,ta/)ar*aa"/Dose" 'etap &er$urua" 'i"$$i :e$eri/,asta pada

A(ad/&olte(/,'/="i./;"sta"si/;"stitut< >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

:;&. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>- i(a +erstatus pe$aai "e$eri sipil

:;& a*asa" >>>>>>>>>>>>>>>>>>>>>>>>>>>>>- de"$a" :omor ,urat )eputusa" a*asa" ,)

terlampir < >>>>>>>>>>>>>>>>>>>>>>>>> pe$aai i(a +erstatus dose" tetap *a*asa"

:;D:. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>- +a$i *a"$ suda% memili(i :;D:

u"tu( me"$i(uti pe"didi(a" a$ister/Do(tor &ro$ram ,tudi < >>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>di ;"stitut 'e("olo$i ,epulu% :opem+er.

="tu( me"ami" (ela"ara" tu$as- selama me"$i(uti pe"didi(a" di &ro$ram &asasara"a

*+s di+e+as(a" dari tu$as ruti" (a"tor atau tu$as a(ademi( da" admi"istrati.

>>>>>>>>>>>>>>>>>- >>>>>>>>>>>>>>>>20>>>

Dir/)et/e(tor- &impi"a"- >>>>>>>>>>>>>>>>>A(ad/&olte(/,'/="i./;"st/;"stitut>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> :;&/:;&.


11/16

"ormulir ekome#asi

"l"m"12

E)?E:DA,; =:'=) CA!?: &E,E'A&?A A;,'E DA: D?)'?@

;:,';'=' 'E):?!?; ,E&=!=# :?&EBE

1. :ama alo">>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

2. 'ela% +erapa lama ,audara me"$e"al alo" da" dalam %u+u"$a" apa

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

3. e"urut ,audara- apa *a"$ merupa(a" u"suru"sur (emampua"/(e(uata" utamaalo"

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

4. e"urut ,audara- apa(a% *a"$ merupa(a" (elema%a"/(e(ura"$a" utama alo"

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

5. e"urut ,audara- %i"$$a +erapa au% alo" tela% memi(ir(a"/mere"a"a(a"/

mempersiap(a" diri u"tu( me"$i(uti pro$ram a$ister/Do(tor

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

@ Coret *a"$ tida( perlu Calo" peserta dapat memper+a"*a(/otoop* sesuai (e+utu%a" ,urat re(ome"dasi dapat dimasu((a" dalam amplop tertutup


12/16

"ormulir ekome#asi

"l"m"12

6. Ba$aima"a(a% ,audara me"ilai alo"uar BiasaBaik

BaikSekali

Baik 6ata?rata !urang'aik

a. )emampua" i"tele(tual

+. )ete(u"a" +elaar/+e(era

. )emampua" me"$atur

pe"$$u"aa" a(tu

d. )emampua" Ba%asa ;"$$ris

atau Ba%asa Asi"$ lai""*a

se+ut(a".

>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>>>>>>>>>>

Pem'eri rekomendasi :

N/M/ :

/B/T/N :

/>/M/T :

T>P7N :

T/N88/> :

T/N#/ T/N8/N :

@ Coret *a"$ tida( perlu Calo" peserta dapat memper+a"*a(/otoop* sesuai (e+utu%a" ,urat re(ome"dasi dapat dimasu((a" dalam amplop tertutup


13/16

"ormulir " sula# Topik Tesis

"l"m

"1

=,=!A: '?&;) &E:E!;';A:CA!?: A#A,;,A BA= &?A A;,'E

&?A &A,CA,AA:A ;',

:ama < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

&ro$ram ,tudi < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

Bida"$ )ea%lia" < >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

=sula" 'opi( /N PN>%T%/N #%S6T/S% se+a"*a(15 20 %alama"-sesuai ormat *a"$ disedia(a" ole% &ro$ram &asasara"a ;', +isa dido"load die+site.pasa.its.a.id

Calo" ma%asisa dapat me"am+a%(a" lem+ar se"diri apa+ila diperlu(a"
http://www.pasca.its.ac.id/http://www.pasca.its.ac.id/http://www.pasca.its.ac.id/http://www.pasca.its.ac.id/


15/16

"ormulir % Keseiaa# *alo#

"l"m

"15

!S#%//N SB/8/% =/>7N PMB%MB%N8UNTU! =/>7N PS6T/ P6786/M #7!T76%NST%TUT T!N7>78% SPU>UH N7PMB6

1! /ama *alo# :

2! 7paka me#uru sauara pe#a'ar sua mempersiapka# re#8a#a

pe#eliia# e#$a# baik

3! 7paka sauara me#yeuui ema pe#eliia# ya#$ iusulka#

pe#a'ar

4! 7paka sauara berseia u#uk me#ai 8alo# promoor ba$i

pe#a'ar ya#$ bersa#$kua# ika ya#$ bersa#$kua# lulus uia#

masuk pro$ram S3

7"lo Promo$or +N"m" + ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

8"3"$" + ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

8uml"' &im3i%" M"'"(i(9" S: ;"% Se!"% Di3im3i% +

,,,,,,,,,,,,,,,,,,,,,,,,

Al"m"$ +

,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

TELEPON + ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

TANGGAL + ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

T/N#/ T/N8/N :

Calo" ma%asisa dapat me"am+a%(a" lem+ar se"diri apa+ila diperlu(a"


16/16

; 7 + I 7 /

"l"m"16

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