PERMOHONAN SURAT AKTIF KULIAH

FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN

UNIVERSITAS JAMBI

ISI DENGAN LENGKAP DAN HURUF CETAK

PROGRAM STUDI : ...............................................................................................................

NAMA : ...............................................................................................................

NIM : ...............................................................................................................

SEMESTER : ...............................................................................................................

TEMPAT /TGL LAHIR : ...............................................................................................................

NAMA ORANG TUA : ...............................................................................................................

ALAMAT : ...............................................................................................................

…...........................................................................................................

NOMOR HP/TELP : ...............................................................................................................

MENGAJUKAN PERMOHONAN UNTUK KEPERLUAN : .......................................................

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

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

Jambi, ................................

Pemohon
 (.........................................)
NB : Lampirkan PC Bukti pembayaran UKT