FORMULIR PENDAFTARAN

LOMBA KARYA CIPTA MARITIM NASIONAL

(LOKARINA)
Judul Karya Tulis Ilmiah : ...................................................................................................................
.....................................................................................................................
Sub Tema : .........................................................................................................................................
Nama Perguran Tinggi : .......................................................................................................................
Alamat Lengkap : ...............................................................................................................................
................................................................................................................................
Jenis Pengiriman Karya :

Online (Softcopy)

Pos (Hardcopy)

Data Diri Penulis

Nama Tim : ....................................................................................................................................
Ketua (Nama/NIM) : ......................................................................................................................
Alamat Lengkap : ............................................................................................................................
Alamat Email : ...............................................................................................................................
No. Telpon/HP : .............................................................................................................................
Anggota (Nama/NIM) : 1. ...............................................................................................................
2. ...............................................................................................................
Dosen Pendamping
Nama Lengkap & Gelar : ................................................................................................................
NIP : ................................................................................................................................................
No Telpon/HP : ................................................................................................................................
, ... 201..
Ketua Kelompok

(..)
NIM.

Formulir Pendaftaran ini agar diisi, kemudian di save, dan di email dalam bentuk Adobe
Acrobat (PDF) paling lambat tanggal 3 Februari 2014 pukul 24.00 WIB ke email
lokarinaits@gmail.com dengan ketentuan penulisan subjek:
Form LOKARINA PTN Nama Tim Kota, atau melalui pos ke alamat
panitia LOKARINA: Himpunan Mahasiswa Teknik Perkapalan (HIMATEKPAL)/Fakultas Teknologi
Kelautan/Institut Teknologi Sepuluh Nopember/Kampus Sukolilo Surabaya 60111
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