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FAKULTAS KEDOKTERAN

UNIVERSITAS ANDALAS

SURAT PERMOHONAN PENERBITAN IZIN PENGAMBILAN DATA / PENELITIAN

Nama :______________________________________________

No. BP :______________________________________________

Alamat :______________________________________________

No. HP :______________________________________________

e-Mail :______________________________________________

Pembimbing 1 :______________________________________________

Pembimbing 2 :______________________________________________

Melaksanakan Kegiatan :______________________________________________

Ditujukan kepada :______________________________________________

Dalam rangka :______________________________________________

Judul :______________________________________________

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Saya yang memohon,

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