Nama : ...............................................................................................
NIM : ...............................................................................................
Program studi : ...............................................................................................
Semester : ...............................................................................................
Sks Kumulatif : ................................................................................................
IPK : ...............................................................................................
Alamat : ...............................................................................................
Telp./HP : ...............................................................................................
Demikian permohonan kami, atas perhatian dan bantuannya kami ucapkan terima kasih.
Materai 6000
................................................ ..................................................
*) Untuk mempermudah pemrosesan surat, isian permohonan surat ini harap diketik/diprint