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

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

Menyetujui: Yang Mengajukan
Ka. Jurusan/Ka. Prodi ............................................

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

F.01-FT-KA-01