KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

UNIVERSITAS BRAWIJAYA
FAKULTAS KEDOKTERAN GIGI
Jalan Veteran, Malang – 65145, Indonesia
Telp. 0341-576161 E-mail : fkg@ub.ac.id http://www.fkg.ub.ac.id

FORMULIR PERMOHONAN IJIN PENELITIAN

Nama :
NIM :
Semester :
No. HP :
Program Studi : Sarjana Kedokteran Gigi
Tujuan Penelitian : Studi Pendahuluan / Uji Validitas / Pengambilan Data / Uji Etik
Judul Proposal
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Dosen Pembimbing : 1. ...........................................................................................
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Tujuan (tempat) : 1. ...........................................................................................
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Malang .................................
Mahasiswa,

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NIM