FORMULIR PENDAFTARAN

PRESENTASI PRAKTEK KERJA LAPANGAN (PKL)

PROGRAM STUDI TEKNIK PERTAMBANGAN

Nama : .................................................................................................................

N.P.M : .................................................................................................................

Alamat :..................................................................................................................

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No. Telephone : .................................................................................................................

Judul PKL : .................................................................................................................

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

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Pembimbing : 1. .............................................................................................................

2. .............................................................................................................

Tenggarong, .......................................20.....
Pendaftar,

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Catatan :
1. Photocopy kuitansi pembayaran Bimbingan PKL sebanyak 1 lembar.
2. Photocopy Sertifikat PKL sebanyak 1 lembar
3. Photocopy SK Pembimbing 1 lembar
4. Photocopy Kartu Tanda Mahasiswa (KTM) sebanyak 1 lembar
5. Photocopy Lembar Konsultasi sebanyak 1 lembar
6. Menyerahkan Draf Laporan PKL sebanyak 2 Eksemplar
7. MAP warna Coklat
 Tenggarong,............................20....

Perihal : Mohon Dijadwalkan Presentasi

Praktek Kerja Lapangan (PKL)

Kepada Yth,
Wakil Dekan I Fakultas Teknik
Cq. Ketua Program Studi
Di_
Tenggarong

Yang bertanda tangan dibawah ini :

Nama : ...............................................................................................................

Tempat/Tanggal Lahir : ...............................................................................................................

N.P.M : ...............................................................................................................
Jurusan :................................................................................................................
Program Studi : ...............................................................................................................
Alamat :................................................................................................................
................................................................................................................
................................................................................................................
Sehubungan telah selesainya penyusunan laporan Praktek Kerja Lapangan (PKL) dan telah
diadakan perbaikan dengan judul :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Dengan Dosen Pembimbing sebagai berikut :
1. ..................................................................
2. ..................................................................

Maka dengan ini saya mohon untuk dijadualkan untuk Presentasikan dimaksud dengan
waktu yang tidak terlalu lama.
Demikian surat permohonan ini kami sampaikan, atas perhatian dan perkenannya diucapkan
terima kasih.

Pemohon,

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