Registration Form | PMB IAIH PANCOR

Academic options*

Regular Program

Integrated Program (terdaftar di MDQH)

Recognition of Prior Learning/Rekognisi Pembelajaran Lampau (RPL)

REGISTRATION CODE*

Alternative Program*

Student's name*

Preferred name

Gender*

Male

Female

Place of Birth*

Date of Birth (DD-MM-YY)*

Nationality*

Previous School*

Medical Diagnosis (if any)

Medications Currently Taken

Contact Number*

Facebook account

Instagram

TikTok

Father's Full Name*

Mother's Full Name*

Responsible Party*

Relationship to Student*

Occupation*

Home Address*

Emergency Contact Number*

Declaration*

I confirm that the information provided is accurate and complete to the best of my knowledge. (Saya menyatakan bahwa informasi yang diberikan adalah benar dan lengkap sesuai pengetahuan saya)

Guidelines Before Filling Out the Form

Ensure all required fields are completed accurately.
Pastikan semua kolom yang wajib diisi telah diisi dengan benar.
Verify the information provided before submission.
Periksa kembali informasi yang diberikan sebelum mengirimkan.
Regular applicants (Non-MDQH) are required to pay a registration fee of IDR 200,000. Payment can be made to DANA: 0818 0987 0987 via Alfamart/Indomaret/Bank Transfer, or by using the QRIS code below.
Bagi calon mahasiswa reguler (tidak terdaftar di MDQH) silakan membayar biaya pendaftaran sebesar Rp.200.000,- (dua ratus ribu rupiah) ke DANA dengan nomor akun 0818 0987 0987 melalui Alfamart/Indomaret/transfer bank, atau QRIS berikut:
Following the completion of your transfer, you are kindly requested to send your proof of payment, Family Card, and Graduation Certificate of SMA/MA/SMK HERE
Setelah menyelesaikan transfer, mohon kirimkan hasil scan bukti pembayaran Anda beserta Kartu Keluarga dan SKHU/SKL/IJAZAH (SMA/MA/SMK) ke SINI
Contact the provided support number for any inquiries or assistance.
Hubungi nomor WhatsApp yang tersedia untuk pertanyaan atau bantuan lebih lanjut.

Panduan Sebelum Mengisi Formulir