KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
POLITEKNIK NEGERI BENGKALIS
JURUSAN TEKNIK SIPIL Jalan Bathin Alam, Sungai Alam Bengkalis-Riau 28714 Telepon (0766) 24566, Faximile (0766) 800 1000 Laman: http//www.polbeng.ac.id FORMULIR 1 T A : 20 . . . /20 . . . PERMOHONAN DAN PENENTUAN JUDUL PROPOSAL TA/SKRIPSI
Saya yang bertandatangan di bawah ini :
Nama : .................................................................... NIM : .................................................................... No. HP : .................................................................... Judul : ................................................................................................................ ................................................................................................................ ................................................................................................................ Deskripsi Umum : ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ Judul ditentukan oleh : = Dosen = Mahasiswa
Demikian permohonan judul proposal ini diusulkan, atas perhatiannya diucapkan
terimakasih.
Mahasiswa,
(.............................................)
Usulan Calon Dosen Pembimbing I
Nama Catatan: 1. Pembimbing harus sesuai dengan kompetensi bidang ilmu 2. Form diserahkan ke Koordinator TA/Skripsi
Certificate SMM ISO 9001 : 2008: ID 16/03476 dan IWA 2: 2007