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MU TAR

I IL B
GG

IY
IN

AH
KOLAH T

AL-AMIN
SE

IN STIT
DR YU
AMA

FORMULIR
PENDAFTARAN WISUDA SARJANA S1
STIT AL-AMIN INDRAMAYU

Nama Lengkap : ...............................................................................................


(sesuai di ijazah SLTA)
No. Pokok/NIRM : ...............................................................................................
Tempat Tanggal Lahir : ...............................................................................................
(Sesuai dengan Ijazah SLTA)
No. Handphone : ...............................................................................................
Nama Orang Tua : ...............................................................................................
Alamat Lengkap : ...............................................................................................
...............................................................................................
Tanggal Sidang Skripsi : ...............................................................................................
Judul Skripsi : ...............................................................................................
...............................................................................................
...............................................................................................
Pesan & Kesan ...............................................................................................
...............................................................................................
...............................................................................................

Indramayu, ………….……… 2015


Wajib menempelkan Photo Calon Wisudawan/i,

Photo
3x4
……………………….

Catatan : Formulir dilampiri Kwitansi Pembayaran Wisuda dan


dikumpulkan Paling Lambat Tanggal 30 April 2015.

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