FORMULIR PENDAFTARAN YUDISIUM

UNIVERSITAS FORT DE KOCK BUKITTINGGI

Nama Lengkap : .............................................................................................................

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

Nomor Induk Mahasiswa : .............................................................................................................

Program Studi : .............................................................................................................

Alamat Lengkap : .............................................................................................................

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

E-mail : .............................................................................................................

Telephon / HP : ............................................................................................................

Bukittinggi, ...............................................................
Peserta Yudisium,

Pas Photo
2x3
..............................................................
(Tanda Tangan & Nama Jelas)

Lampiran :
1. Print-Out judul Tugas Akhir (portal) Syarat Pas Photo :
2. Soft Pas Photo Latar Merah Bagi peserta perempuan:
3. Ijazah dan transkrip terakhir sebanyak 1 1. Memakai pakaian kebaya sopan, rapi,
lembar tidak transparan
4. Ijazah dan KTP sebanyak 1 lembar diserahkan 2. Pas Photo bersifat resmi
ke Bagian Adak 3. Boleh memakai jilbab
Bagi peserta laki-laki :
1. Memakai pakaian jas resmi
2. Pas photo bersifat resmi

PERSETUJUAN / BEBAS TANGGUNGAN

Bendahara, Penanggungjawab Ka.UPT Perpustakaan, Bagian Evaluasi/ Ka. UPT
Thesis/Skripsi/ Koordinator Prodi, Laboratorium
LTA/KTI

Imam Saputra, S.TP Romy Firnanda, S.Sos Wahyuni, S.ST,

M.Biomed

**Formulir dan lampiran sudah dapat diterima di Bagian Admin Prodi paling lambat 1
minggu sebelum jadwal yudisium
 FORMULIR PENDAFTARAN WISUDA
UNIVERSITAS FORT DE KOCK BUKITTINGGI

Nama Lengkap : ............................................................................................................

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

Nomor Induk Mahasiswa : .............................................................................................................

Program Studi : .............................................................................................................

Tanggal Yudisium : .............................................................................................................

Alamat Lengkap : .............................................................................................................

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

E-mail : ...........................................................................................................

Telephon / HP : ............................................................................................................

Judul Skripsi/LTA/KTI : .............................................................................................................

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

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

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

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

Bukittinggi, ..............................................................
Peserta Wisuda,
Pas Photo
2x3
..............................................................
(Tanda Tangan & Nama Jelas)

PERSETUJUAN / BEBAS TANGGUNGAN

Bendahara, Ka.UPT Perpustakaan, Bagian Kemahasiswaan,

Imam Saputra, S.TP Romy Firnanda, S.Sos

**Formulir sudah dapat diterima di Bagian Admin Prodi paling lambat1 minggu sebelum
jadwal wisuda
 PERSETUJUAN MAHASISWA AKTIF KEMBALI
UNIVERSITAS FORT DE KOCK BUKITTINGGI

Nama Lengkap : ............................................................................................................

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

Nomor Induk Mahasiswa : .............................................................................................................

Program Studi : .............................................................................................................

Alamat Lengkap : .............................................................................................................

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

E-mail : ...........................................................................................................

Telephon / HP : ............................................................................................................

Bukittinggi, ............................................................
Mahasiswa,

.......................................................
(Tanda Tangan & Nama Jelas)

Ka.Prodi, Bendahara,
Yang Bersangkutan telah menyelesaikan semua
administrasi keuangan

Imam Saputra, S.TP

PERSETUJUAN & BEBAS TANGGUNGAN MAHASISWA BSS (CUTI)
UNIVERSITAS FORT DE KOCK BUKITTINGGI

Nama Lengkap : ............................................................................................................

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

Nomor Induk Mahasiswa : .............................................................................................................

Program Studi : .............................................................................................................

Alamat Lengkap : .............................................................................................................

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

E-mail : ...........................................................................................................

Telephon / HP : ............................................................................................................

Bukittinggi, ............................................................
Mahasiswa BSS,

.......................................................
(Tanda Tangan & Nama Jelas)

Bendahara, Ka.UPT Perpustakaan ,

Yang Bersangkutan telah menyelesaikan semua Yang Bersangkutan telah mengembalikan semua
administrasi keuangan buku pinjaman

Imam Saputra, S.TP Romy Firnanda, S.Sos

 PERSETUJUAN & BEBAS TANGGUNGAN MAHASISWA PINDAH
UNIVERSITAS FORT DE KOCK BUKITTINGGI

Nama Lengkap : ............................................................................................................

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

Nomor Induk Mahasiswa : .............................................................................................................

Program Studi : .............................................................................................................

Alamat Lengkap : .............................................................................................................

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

E-mail : ...........................................................................................................

Telephon / HP : ............................................................................................................

Bukittinggi, ............................................................
Mahasiswa Pindah,

.......................................................
(Tanda Tangan & Nama Jelas)

Bendahara, Pustakawan, Ka.Prodi,

Yang Bersangkutan telah Yang Bersangkutan telah Yang Bersangkutan telah
menyelesaikan semua mengembalikan semua buku menyelesaikan administrasi pada
administrasi keuangan pinjaman Program Studi

Imam Saputra, S.TP Romy Firnanda, S.Sos