SURAT PERMOHONAN TUKAR LOKASI

Yang bertanda tangan di bawah ini, saya:

1. Nama

:..........................................................................,Jenis Kelamin ( L / P )*

2. NIM

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

3. Fakultas

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

4. No.Telp./ Hp

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

Sebagai pihak yang ditempatkan di lokasi KKN-BBM Desa/Kelurahan .....................................

Kecamatan ...................................................... , Kota/Kabupaten .................................................
menyatakan ingin bertukar lokasi dengan alasan : .......................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
dengan mahasiswa / wi berikut :
1. Nama

:..........................................................................,Jenis Kelamin ( L / P )*

2. NIM

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

3. Fakultas

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

4. No.Telp./ Hp

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

Yang ditempatkan di lokasi KKN-BBM Desa/Kelurahan............................................................

Kecamatan ...................................................... , Kota/Kabupaten .................................................
Demikian permohonan kami dan terima kasih atas perhatiannya.

Pemohon I

Surabaya, .......................................
Pemohon II

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

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

Menyetujui,
WAKIL DEKAN I
Fakultas :..............................................................

......................................................
NIP. ..............................................
Keterangan:
* Lingkari yang sesuai
Persetujuan Wakil Dekan I disertai cap/stempel fakultas