Kepada :
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di
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Yang bertanda tangan dibawah ini :
Nama : ..........................................................................................
NIM : ..........................................................................................
Mengajukan judul untuk pembuatan skripsi
Judul : ...................................................................................................
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Waktu : ...................................................................................................
Genggong, ........................................
Pembimbing 1, Mahasiswa,
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Mengetahui,
Koordinator Ujian Akhir,
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