Form Penggunaan Lab

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
Telp./Fax. : + 62-341-559054
Formulir Pengguna Laboratorium (Tentatif)

Nama
NIM/NIP*
Instansi
Tujuan
Judul Penelitian
Lama Penggunaan

2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
No. Telp/HP
Pembayaran
- Uang muka
: .................................................................................................................
- Sisa
: .................................................................................................................
- Lunas
: .................................................................................................................
Penerima,
Malang, ............................, 20......

Pemohon,
(...........................................)
(.............................................)
Coret yang tidak perlu
Telp./Fax. : + 62-341-559054
Formulir Pengguna Laboratorium (Bulanan)

Nama
NIM/NIP*
Instansi
Tujuan
Judul Penelitian
Lama Penggunaan

2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
No. Telp/HP
Pembayaran
- Uang muka
: .................................................................................................................
- Sisa
: .................................................................................................................
- Lunas
: .................................................................................................................
Penerima,
Malang, ............................, 20......

Pemohon,
(...........................................)
(.............................................)
* Coret yang tidak perlu
Telp./Fax. : + 62-341-559054
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,
(...........................................)
(.............................................)
Telp./Fax. : + 62-341-559054
Formulir Perpanjangan Penggunaan Laboratorium (Tetap)

Nama
NIM/NIP*
Instansi
Tujuan
Judul Penelitian
Lama Penggunaan

2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
No. Telp/HP
Pembayaran
- Uang muka
: .................................................................................................................
- Sisa
: .................................................................................................................
- Lunas
: .................................................................................................................
Penerima,
Malang, ............................, 20......

Pemohon,
(...........................................)
(.............................................)
Telp./Fax. : + 62-341-559054
Formulir Perpanjangan Penggunaan Laboratorium (Tentatif)

Nama
NIM/NIP*
Instansi
Tujuan
Judul Penelitian
Lama Penggunaan

2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
No. Telp/HP
Pembayaran
- Uang muka
: .................................................................................................................
- Sisa
: .................................................................................................................
- Lunas
: .................................................................................................................
Penerima,
Malang, ............................, 20......

Pemohon,
(...........................................)
(.............................................)
Telp./Fax. : + 62-341-559054
Formulir Perpanjangan Penggunaan Laboratorium (Bulanan)

Nama
NIM/NIP*
Instansi
Tujuan
Judul Penelitian
Lama Penggunaan

2. ................................................ 7. .......................................................
3. ................................................ 8. .......................................................
4. ................................................ 9. .......................................................
5. ................................................ 10. ......................................................
No. Telp/HP
Pembayaran
- Uang muka
: .................................................................................................................
- Sisa
: .................................................................................................................
- Lunas
: .................................................................................................................
Penerima,
Malang, ............................, 20......

Pemohon,
(...........................................)
(.............................................)
Telp./Fax. : + 62-341-559054

Form Penggunaan Lab

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KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Pengguna Laboratorium (Tetap)

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

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

Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Pengguna Laboratorium (Tentatif)

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

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

Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Pengguna Laboratorium (Bulanan)

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

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

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Pengguna Laboratorium (Anggota Peneliti)

Nama Peneliti Utama:

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

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Perpanjangan Penggunaan Laboratorium (Tetap)

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

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

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Perpanjangan Penggunaan Laboratorium (Tentatif)

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

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

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

Formulir Perpanjangan Penggunaan Laboratorium (Bulanan)

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

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

* Coret yang tidak perlu

KEMENTERIAN PENDIDIKAN NASIONAL

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