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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 : ................................................................................................................
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Deskripsi Umum : ................................................................................................................
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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

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