KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

UNIVERSITAS JENDERAL SOEDIRMAN

FAKULTAS PERIKANAN DAN KELAUTAN
Jalan dr. Suparno Komp. GOR Susilo Sudarman Karangwangkal Purwokerto
Telp. & Fax. (0281) 642360 & 7607433 Website : fpik.unsoed.ac.id

FORMULIR PENGAJUAN KERJA PRAKTEK (Ijon/Biasa)

Nama mahasiswa : ........................................................................................................................................................................
NIM : ........................................................................................................................................................................
Program Studi : ........................................................................................................................................................................
Judul : ........................................................................................................................................................................
........................................................................................................................................................................
Permasalahan : ........................................................................................................................................................................
(Jika tidak cukup bisa ditulis ........................................................................................................................................................................
dilembar terpisah) ........................................................................................................................................................................
........................................................................................................................................................................
1. Pembimbing Akademik
Prasarat : …………………… SKS KARTU SEMINAR
IPK : …………………… DISETUJUI
Jumlah Nilai E : …………………… TIDAK DISETUJUI
Komentar : ……………………

Purwokerto,……………………….20…….
Pembimbing Akademik,

(…………………………………..)
2. Sekretariat Komisi
Persyaratan Administrasi
Sudah Lengkap Belum Lengkap

Purwokerto,……………………….20…….
Petugas Komisi,

(…………………………………..)
3. Riwayat Konsultasi (Jika Ada)
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Nama Dosen Tanda Tangan
1. …………………………………………………. 1. ………………………………………………….
2. …………………………………………………. 2. ………………………………………………….
3. …………………………………………………. 3. ………………………………………………….
4. …………………………………………………. 4. ………………………………………………….
4. Ketua Program Studi
Kesesuaian topik penelitian dengan program Studi
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………

Usulan Calon Pembimbing : …………………………………………………………….

Purwokerto,……………………….20…….
Kaprodi,

(…………………………………..)
5. Tim Komisi Tugas Akhir
Pembimbing : ………………………………………………………………………

Catatan : …………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
1. Ir. H. Arif Mahdiana, M.Si. : Purwokerto,……………………….20…….
2. Emyliana Listiowati, S.Si.M.Sc. : Ketua Komisi Tugas Akhir,
3. R. Taufan Harisam, S.Pi., M.Si :
Ir.Arif Mahdiana, M.Si.
NIP. 19590126 198601 1 001
Mahasiswa melampirkan :
- Daftar nilai/Transkip sementara - Semua syarat dimasukkan stopmap biru ( wajib )
- FC KSM terakhir yang mencantumkan KP