Nama Mahasiswa : .....................................................
NIM : ..................................................... Tempat/Tanggal Lahir : ..................................................... Jurusan : ..................................................... Program Studi : ..................................................... Perolehan SKS : ......................... IP. Kumulatif : ......................... Alamat Asal : ............................................................................ ............................................................................ No. Telefon/HP. : ............................................................................ Lokasi Magang Kerja* : ............................................................................ ............................................................................ * Coret salah satu : (Lokasi terdaftar / Belum terdaftar) Alamat Lokasi Magang : ............................................................................ ............................................................................ ............................................................................ Alamat Tujuan Surat : ............................................................................ ............................................................................ ............................................................................ Komoditi : ..............................................
Malang, Mengetahui Mahasiswa, Dosen Pembimbing Magang,