FORMULIR PERSETUJUAN PENGUJI

UJIAN KARYA TULIS ILMIAH

PROGRAM STUDI DIII ANALIS KESEHATAN

1. Nama Mahasiswa : ...................................................................................................

2. NIM Mahasiswa : ...................................................................................................
3. Judul Karya Tulis Ilmiah
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4. Rencana Ujian Proposal/ Laporan/ Seminar Karya Tulis Ilmiah*
a. Tanggal : ..............................................................................................................
b. Tempat : ..............................................................................................................
c. Waktu : ..............................................................................................................
Surakarta,...............................................
Menyetujui,

Ketua Penguji :

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Sekretaris Penguji :

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Anggota Penguji :

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Lampiran yang harus dilengkapi (diisi panitia): diberi tanda cek () jika sudah dilampirkan

 Persetujuan pembimbing
 Kartu Bimbingan Karya Tulis Ilmiah
 Proposal/ Laporan (3 eksemplar)/ Artikel (1 eksemplar) Karya Tulis Ilmiah

*coret salah satu