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Tgl. Pemesanan :
Form AKA-009
Tgl. Diambil :

FORM PEMBUATAN SURAT-SURAT KP DAN TA


Jenis surat yang diminta *) :

Surat Permohonan KP Surat Permohonan Survey untuk TA

Surat Permohonan Ijin Survey Lain-lain (conditional letter), sebutkan :

................................................................................

Lengkapi data berikut :


Nama : .....................................................................................................................................
NIM : .....................................................................................................................................
Program Studi : .....................................................................................................................................
Semester : .....................................................................................................................................
No. Telp. / Alamat Email : .....................................................................................................................................
Instansi Tujuan : .....................................................................................................................................
Alamat Instansi : .....................................................................................................................................
.....................................................................................................................................

(Khusus untuk Surat Permohonan KP) :


Tanggal Pelaksanaan KP : .....................................................................................................................................
Bidang yang akan dikaji : 1. .................................................................................................................................
2. ................................................................................................................................
3. ................................................................................................................................
4. ................................................................................................................................

(Khusus untuk Surat Permohonan Survey) :


Judul TA : .....................................................................................................................................
Data-data yang disurvey : 1. .................................................................................................................................
2. ................................................................................................................................
3. ................................................................................................................................
4. ................................................................................................................................

Menyetujui, Pemohon,

.......................................................... ...............................................................
Koord. KP / Koord. PA

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