PERNYATAAN KESEDIAAN MENJADI ANGGOTA ASOSIASI DOSEN

INDONESIA (ADI) WILAYAH JAWA TIMUR

Nama (lengkap dengan gelar akademik) :....................................................................................................

Tempat,tgl.lahir :...................................................................................................
Jabatan Akademik :...................................................................................................
NIDN :...................................................................................................
Jenis kelamin :...................................................................................................
Agama :....................................................................................................
Alamat Rumah & Tilp. :....................................................................................................
.....................................................................................................
.....................................................................................................
Tilp.............................................................................................

Alamat Kantor & Tilp. :.....................................................................................................

.....................................................................................................
.....................................................................................................
.....................................................................................................
Tilp............................................Fax.............................................

HP : ...................................................................................................
E-mail : ...................................................................................................

Tanpa tekanan dari mana pun, dengan kesadaran penuh, saya mendaftarkan diri dan bersedia
menjadi anggota Asosiasi Dosen Indonesia (ADI) Wilayah Jawa Timur.

Probolinggo, ........................
Yang membuat pernyataan

...................................................
Nama terang

Mengetahui dan Menyetujui,

Asosiasi Dosen Indonesia Wilayah Jawa Timur

Ketua Umum Sekretaris

Prof. Dr. Ir. H. Darsono Wisadirana, MS Dr.Bambang Dwi Prasetyo,M.Si.

NA.195612270320090001 NA. 197204280320090005

Note : - Agar disertakan foto berwarna ukuran 2x3 sebanyak 3 lembar untuk kartu anggota ADI
- Biaya Registrasi sebesar Rp. 100.000,-

Sekretariat ADI Wilayah Jawa Timur :

Gedung FISIP UB Lantai 1, Jl. Veteran Malang 65145
Telp : (0341) 575755, 085648610211 Fax : (0341)570038
Email : adi.jatim@yahoo.com, web : www.adi.jatim.ub.ac.id