Nomor : Yogyakarta,....................................

Hal : Permohonan Cuti Kuliah

Lamp. :

Kepada Yth. :
Bapak Rektor Universitas Negeri Yogyakarta
di Yogyakarta

Yang bertanda tangan di bawah ini :

1. Nama : ...............................................................................................................
2. No. Mahasiswa : ...............................................................................................................
3. Status Masuk : UMPTN PBU SM PKS*)
4. Program Studi : ...............................................................................................................
5. Fakultas : ...............................................................................................................
6. Jumlah SKS Kumulatif yang ditempuh : ...............................................................................................................
7. IP Kumulatif : ...............................................................................................................
8. Semester : ...............................................................................................................
9. Tahun Akademik : ...............................................................................................................
10.Alasan Cuti Kuliah : ...............................................................................................................
11.Pernah mengambil Cuti Kuliah : pernah/tidak *)
Jika pernah diambil pada : 1. semester................(................/................)
2. semester................(................/................)
3. semester................(................/................)
12. Alamat selama menjalankan Cuti Kuliah di : ...............................................................................................................
...............................................................................................................

Terlampir disampaikan copy Kartu Mahasiswa, KHS yang telah ditempuh.

Atas ijin yang diberikan, diucapkan terima kasih.

Mengetahui Hormat kami,

Penasehat Akademik

................................................ .................................................
NIP. ......................................... NIP. ...........................................

Dekan Fakultas Ilmu Pendidikan Ketua Jurusan

Universitas Negeri Yogyakarta

................................................. .................................................
NIP. ......................................... NIP. .........................................

Tembusan Yth. :
1. Kabag. Pendidikan dan Kerjasama
Universitas Negeri Yogyakarta
*) Coret yang tidak perlu
- Penyerahan permohonan Cuti Kuliah di Registrasi
Paling lambat tanggal
- Diluar tanggal tersebut tidak diproses