KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

UNIVERSITAS LAMPUNG
FAKULTAS TEKNIK
Jl. Prof. Soemantri Brojonegoro No. 1 Bandar Lampung 35145
Telp. (0721) 704947 Fax (0721) 704947

BLANGKO
SURAT KETERANGAN MASIH KULIAH

Nama

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

NPM

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

Jurusan/Prodi

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

Tahun Akademik/Semester

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

Nama Orang Tua

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

Pekerjaan

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

Instansi/Tempat Kerja

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

NIP

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

Pangkat/Golongan

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

Alamat Rumah

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

Menyetujui:
Ka. Jurusan/Ka. Prodi ............................................

( .......................................... )
NIP ......................................

Bandar Lampung, ................................

Yang Mengajukan

( ....................................... )
NPM .................................

Lampirkan:
1. Foto Kopi Slip SPP terakhir
2. Foto Kopi KP4 bagi orang tua yang PNS/ABRI
3. Surat Keterangan dari Perusahaan bagi orang tua yang Pegawai Swasta