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KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Pengguna Laboratorium (Tetap)


Nama

NIM/NIP*

Instansi

Tujuan

Judul Penelitian

Pembimbing/Promotor * :...

Lama Penggunaan

Alat yang digunakan : 1. ................................................ 6. .......................................................


2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
Diteruskan ke Divisi : .................................................................................................................
No. Telp/HP

Pembayaran
- Uang muka

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

- Sisa

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

- Lunas

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

Penerima,

Malang, ............................, 20......


Pemohon,

(...........................................)

(.............................................)

Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Pengguna Laboratorium (Tentatif)


Nama

NIM/NIP*

Instansi

Tujuan

Judul Penelitian

Pembimbing/Promotor * :...

Lama Penggunaan

Alat yang digunakan : 1. ................................................ 6. .......................................................


2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
Diteruskan ke Divisi : .................................................................................................................
No. Telp/HP

Pembayaran
- Uang muka

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

- Sisa

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

- Lunas

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

Penerima,

Malang, ............................, 20......


Pemohon,

(...........................................)

(.............................................)

Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Pengguna Laboratorium (Bulanan)


Nama

NIM/NIP*

Instansi

Tujuan

Judul Penelitian

Pembimbing/Promotor * :...

Lama Penggunaan

Alat yang digunakan : 1. ................................................ 6. .......................................................


2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
Diteruskan ke Divisi : .................................................................................................................
No. Telp/HP

Pembayaran
- Uang muka

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

- Sisa

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

- Lunas

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

Penerima,

Malang, ............................, 20......


Pemohon,

(...........................................)

(.............................................)

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Pengguna Laboratorium (Anggota Peneliti)


Nama

NIM/NIP*

Instansi

Tujuan

Nama Peneliti Utama:


Judul Penelitian

Lama Penggunaan

Diteruskan ke Divisi :
No. Telp/HP

Penerima,

Malang, ................................. 20......


Pemohon,

(...........................................)

(.............................................)

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Perpanjangan Penggunaan Laboratorium (Tetap)


Nama

NIM/NIP*

Instansi

Tujuan

Judul Penelitian

Pembimbing/Promotor * :...

Lama Penggunaan

Alat yang digunakan : 1. ................................................ 6. .......................................................


2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
Diteruskan ke Divisi : .................................................................................................................
No. Telp/HP

Pembayaran
- Uang muka

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

- Sisa

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

- Lunas

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

Penerima,

Malang, ............................, 20......


Pemohon,

(...........................................)

(.............................................)

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Perpanjangan Penggunaan Laboratorium (Tentatif)


Nama

NIM/NIP*

Instansi

Tujuan

Judul Penelitian

Pembimbing/Promotor * :...

Lama Penggunaan

Alat yang digunakan : 1. ................................................ 6. .......................................................


2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
Diteruskan ke Divisi : .................................................................................................................
No. Telp/HP

Pembayaran
- Uang muka

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

- Sisa

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

- Lunas

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

Penerima,

Malang, ............................, 20......


Pemohon,

(...........................................)

(.............................................)

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id

Formulir Perpanjangan Penggunaan Laboratorium (Bulanan)


Nama

NIM/NIP*

Instansi

Tujuan

Judul Penelitian

Pembimbing/Promotor * :...

Lama Penggunaan

Alat yang digunakan : 1. ................................................ 6. .......................................................


2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
Diteruskan ke Divisi : .................................................................................................................
No. Telp/HP

Pembayaran
- Uang muka

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

- Sisa

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

- Lunas

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

Penerima,

Malang, ............................, 20......


Pemohon,

(...........................................)

(.............................................)

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS BRAWIJAYA
LABORATORIUM SENTRAL ILMU HAYATI (LSIH)
Jl. Veteran Malang 65145, Indonesia
Telp./Fax. : + 62-341-559054
http://lsih.brawijaya.ac.id; E-mail: labsentralub@brawijaya.ac.id; lsih_ub@yahoo.co.id