DOKUMENTASI KELULUSAN

FAKULTAS

: SASTRA

PROGRAM STUDI

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

TAHUN AKADEMIK

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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Nomor Induk Mahasiswa (NIM)

Nama Lengkap
Tempat / Tanggal Lahir
Jenis Kelamin
Agama
Warga Negara
Alamat
Alamat Sekarang
No. HP
Riwayat Pendidikan
SD :
SLTP:
SLTA:
Diploma
11. Status Sipil
12. Nama Istri / Suami
13. Nama Orang Tua

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:L/P
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Nama di Ijazah
Nama Sekolah
Tahun Lulus
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: Kawin / tidak kawin
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:

14. Tanggal Lulus

15. Judul Tugas Akhir

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: 1............................................................No. Surat Tugas:
2............................................................
3............................................................
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:.................................................... No. Surat Tugas:...............
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: ........ semester
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16. Judul English

17. Penguji

18.
19.
20.
21.
22.

Nama Pembimbing 1
Nama Pembimbing 2
Nama Dosen Wali
Pernah Cuti
Kegiatan Extrakurikuler

Mengetahui
Pembantu Dekan I,

Foto
3*4

Jember,..
Tanda Tangan

ditempel
dulu baru
difotocopy

Drs. Albert Tallapessy, M.A.Ph.D

NIP.196304111988021001

.
NIM.

Catatan :
Isilah Dokumentasi ijazah ini dengan jelas sesuai ijazah SMU;
Dikumpulkan dalam1 map, rangkap 3 berisi :
1. Dokumentasi kelulusan, transkirp, ijazah terakhisr;
2. Foto hitam putih, kertas dop ukuran 3*4 (15 lbr) jas warna terang selain putih.
3. Bukti bebas SPP, pembayaran wisuda & yudisium, penyerahan bendel, bebas pustaka.