PERNYATAAN KEIKUTSERTAAN

Yang bertanda tangan dibawah ini,

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

Tempat/Tanggal Lahir :.....................................................................................

Asal Universitas :.....................................................................................

NIM :.....................................................................................

Jurusan/Prodi/Semester :.....................................................................................

Alamat :.....................................................................................

Alamat Universitas :.....................................................................................

Kode Pos :.....................................................................................

Alamat Rumah :.....................................................................................

Telp :.......................................................

Mewakili tim saya yang beranggotakan :

Mahasiswa : (1).........................................................................

(2).........................................................................

(3).........................................................................

(4).........................................................................

Menyatakan bersedia mengikuti Lomba Eco House Design Competition IX yang

diselenggarakan Keluarga Mahasiswa Teknik Sipil UGM.

Dibuat di:

Pada tanggal:

Menyetujui Yang membuat pernyataan,

Kadep/ Kaprodi/ Bidang Kemahasiswaan Ketua Tim

(………………………………………………) (………………………………………………)
NIP. NIM.