FORMULIR LAPOR DIRI PULANG KAMPUNG MAHASISWA

FAKULTAS MATEMATIKA DAN ILMU PENGETAHUAN ALAM

I. DATA MAHASISWA

Nama : ...........................................................................................................

NPM : ...........................................................................................................

Departemen : ...........................................................................................................

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

No. HP : ...........................................................................................................

No. Telp Rumah : ...........................................................................................................

Alamat Kos : ...........................................................................................................

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

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

II. DATA ORANG TUA

Nama Ayah : ...........................................................................................................

Nama Ibu : ...........................................................................................................

Alamat Rumah Ayah : ...........................................................................................................

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

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

Alamat Rumah Ibu : ...........................................................................................................

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

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

No. HP Ayah : ...........................................................................................................

No. HP Ibu : ...........................................................................................................

(Seluruh isian bersifat wajib untuk diisi)

III. DATA KEPULANGAN MAHASISWA

Alamat Rumah : ................................................................................................

(Tujuan Pulang) ................................................................................................

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

Transportasi Kepulangan : ................................................................................................

Rencana Durasi Kepulangan : ............................................................................. hari/bulan

Tanggal Kepulangan : .......................................................................................2020

Tanggal Kembali ke Depok : .......................................................................................2020

Depok, ............................ 2020

Pemohon Ijin

......................................................
NPM. ............................................

(Seluruh isian bersifat wajib untuk diisi)