KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

UNIVERSITAS BRAWIJAYA

PROGRAM KEDOKTERAN HEWAN

Form-1

PROGRAM STUDI : S-1 PENDIDIKAN DOKTER HEWAN

Jl. M.T. Haryono 169 Malang 65145 Telp/Fax. 0341-573642 Email : pskh_ub@ub..ac.id

Pengajuan Rencana PKL

Semester

: Ganjil / Genap

Tahun Akademik : ..........................................

NIM

: .................................. Nama MHS : ..................................................

No HP

:............................................... (Yang Bisa Dihubungi)

IP Kumulatif

: ................................

Judul

: ..........................................................................................................

SKS Kumulatif : ............................................

..........................................................................................................................................
..........................................................................................................................................
Nama Instansi PKL
Alamat Instansi

: .......................................................................................................

: ............................................................................................................

Kec ................................ Kota ......................................Propinsi : ....................................

Tanggal Pelaksanaan : .....................................................................................................
Calon Pembimbing
Pembimbing 1 : .....................................................................
NIP

: ......................................................................

Pembimbing 2 : .....................................................................
NIP

: ......................................................................

Pembimbing hanya isi oleh Wakil Bidang Akademik

Malang, ....................................
Wakil Bidang Akademik

Yang Mengajukan,

Prof.Dr.Aulanni'am,drh.,DES
NIP. 19600903 198802 2 001

............................................................

Persyaratan :
KRS & KHS Terbaru Dan Stofmap Folio Warna Hijau.
Surat Pengantar Dari Kasubag Akademik-PKH-UB.
Proposal.

NIM....................................................