Form yang sudah diisi paling lambat dikirim pada tanggal 28 Februari 2019

Ke email : bicorner.2019@gmail.com

FORMULIR IDENTIFIKASI CALON PENERIMA BANTUAN

PROGRAM SOSIAL BANK INDONESIA (PSBI)

Nama Lembaga/Pemohon :
Alamat :
No.Telepon :
Narasumber dan Jabatan :
Usulan Kegiatan : Program BI Corner

KELEMBAGAAN (UNIVERSITAS/SEKOLAH)
1. Kapan lembaga berdiri ?
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........................................................................................................................................................................

2. Jelaskan latar belakang, tujuan atau visi lembaga ?

Latar Belakang
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Tujuan
........................................................................................................................................................................
........................................................................................................................................................................
Visi : ......................................................................................................................................................
Misi : ......................................................................................................................................................

3. Jelaskan perkembangan lembaga sampai dengan saat ini ?

Jumlah mahasiswa/anggota : ......................................................................................................................
Status akreditasi : ......................................................................................................................
Program Studi : ......................................................................................................................
Prestasi (jika ada) :
........................................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................

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Form yang sudah diisi paling lambat dikirim pada tanggal 28 Februari
2019 Ke email : bicorner.2019@gmail.com

4. Jelaskan sumber dana lembaga ?

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

5. Jelaskan pengalaman atau track record kegiatan yang dilaksanakan Lembaga (2 tahun terakhir)?
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6. Jelaskan manfaat keberadaan lembaga bagi masyarakat ?

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

KEPENGURUSAN/PESERTA/ANGGOTA (PERPUSTAKAAN)
1. Jelaskan struktur organisasi, jumlah dan siapa yang menjadi pengurus lembaga?
........................................................................................................................................................................
........................................................................................................................................................................
2. Jelaskan latar belakang (sosial ekonomi dan pendidikan) pengurus/peserta/anggota?
........................................................................................................................................................................
........................................................................................................................................................................
3. Bagaimana tingkat keaktifan pengurus pada kegiatan di lembaga?
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........................................................................................................................................................................
4. Kondisi perpustakaan :
Jumlah buku yang dimiliki : ...........................................................................
Jumlah pustakawan : ...........................................................................
Jumlah rata-rata pengunjung per 1 hari : ...........................................................................

KEGIATAN
1. Kegiatan apa yang akan dilaksanakan dan membutuhkan bantuan dari Bank Indonesia ?
........................................................................................................................................................................
........................................................................................................................................................................

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Form yang sudah diisi paling lambat dikirim pada tanggal 28 Februari
2019 Ke email : bicorner.2019@gmail.com

2. Apa latar belakang dan tujuan dilaksanakannyakegiatan tersebut?

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

3. Siapa target penerima manfaat kegiatan?

Internal :
Eksternal :

4. Berapa rincian biaya/anggaran kegiatan tersebut?

Sesuai dengan anggaran dari Bank Indonesia

5. Darimana sumber pendapatan untuk melaksanakan kegiatan tersebut?

Bank Indonesia

6. Foto ruangan perpustakaan dan sudut yang diajukan pembangunan BI Corner (foto terbaru)
a. Ruangan perpustakaan (3 foto)
b. Space dalam ruangan yang diajukan pemasangan BI Corner (3 foto)