LOG BOOK

PROGRAM KREATIVITAS MAHASISWA (PKM)

Skema Program
PKMP/PKMK/PKMM/PKMT/PKMKC*
Judul

Ketua
------------------------------------

KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

UNIVERSITAS SEBELAS MARET SURAKARTA
TAHUN 2012

Identitas Pelaksana

1. Judul

................................................................................................................

2. Ketua:
Nama

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

NIM

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

Jurusan/Fak.

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

Tlp/Hp

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

Alamat Rumah

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

3. Anggota
1) Nama
: ................................................................................................................
NIM

................................................................................................................

Jurusan/Fak.
: ................................................................................................................
2) Nama
: ................................................................................................................
NIM

................................................................................................................

Jurusan/Fak.
: ................................................................................................................
3) Nama
: ................................................................................................................
NIM

................................................................................................................

Jurusan/Fak.
: ................................................................................................................
4) Nama
: ................................................................................................................
NIM

................................................................................................................

Jurusan/Fak.
: ................................................................................................................
4. Dosen Pembimbing
Nama

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

NIP

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

Tlp/Hp

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

Alamat Rumah

.....

.....

................................................................................................................

5. Jangka

Waktu

Pelaksanaan : ..................................................................................................
6. Lokasi Kegiatan

................................................................................................................

7. Dana Kegiatan

Rp. .........................................................................................................
8. Sumber Dana

: DP2M Tahun Anggaran 2012

NO TANGGAL

PELAKSANA

KEGIATAN

INDIKATOR KEBERHASILAN

TEMPAT

TANDA
TANGAN
PEMBIMBING