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FORM

PEMINJAMAN BARANG/PERALATAN

Nama Kegiatan : .................................................................................................

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

Lembaga Pengusul : .................................................................................................

Nama Pemohon : .................................................................................................

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

Tanggal Pemakaian : ......................................... s/d ......................................... 20....

Tempat Pelaksanaan : .................................................................................................

Daftar Barang / Alat yang Dipinjam

No Nama Barang / Alat Jumlah


1
2
3
4
5
6
7
8
9
10

Malang, ……………….201….
Menyetujui,
Kasubag UMUM dan BMN

BAYU PARIPURNA, SE
NIP. 1977003122005011001

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