SEKOLAH TINGGI ILMU KESEHATAN ( STIKES )

CITRA DELIMA BANGKA BELITUNG

Jalan Pinus I Kacang Pedang Atas Pangkalpinang – 33125
Telepon (0717) 422531 Email : STIKESCD@yahoo.co.id

FORM DATA MAHASISWA PESERTA WISUDA

TAHUN AKADEMIK 20 ..... / 20 .....

NAMA LENGKAP ( SESUAI IJAZAH) : ................................................................................................................

TEMPAT / TANGGAL LAHIR : ................................................................................................................
NOMOR INDUK MAHASISWA : ................................................................................................................
NO. INDUK KEPENDUDUKAN (KTP) : ................................................................................................................
AGAMA : ................................................................................................................
ALAMAT EMAIL : ................................................................................................................
NO. HP : ................................................................................................................
ALAMAT LENGKAP : ................................................................................................................
KEC. ......................................................................................................
KAB./KOTA .........................................................................................
NAMA ORANG TUA
 AYAH : ................................................................................................................
 IBU : ................................................................................................................
PROGRAM STUDI : ................................................................................................................
JUDUL SKRIPSI / TUGAS AKHIR
 BAHASA INDONESIA : ................................................................................................................
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 BAHASA INGGRIS : ................................................................................................................

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IPK : ................................................................................................................

........................................, ....................................... 20 ....

MAHASISWA,

TTD

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CATATAN :

1. DIISI DENGAN HURUF BALOK

2. FORM DATA MAHASISWA DIBUAT 2 RANGKAP
3. LAMPIRKAN FOTOKOPI IJAZAH TERAKHIR SEBANYAK 1 LEMBAR
4. LAMPIRKAN FOTOKOPI KTP SEBANYAK 1 LEMBAR
5. TERJEMAHAN JUDUL SKRIPSI / TUGAS AKHIR KE DALAM BAHASA INGGRIS DIBUAT SESUAI
DENGAN TERJEMAHAN YANG BENAR.
6. BERKAS DIKUMPULKAN KE BAAK PALING LAMBAT TANGGAL 24 SEPTEMBER 2020.