KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN No.

Form
UNIVERSITAS JEMBER F1 US010710001
Jl. Kalimantan 37 Kampus Tegal Boto Kotak Pos 159
Telp. (0331)-330224, 336579, 336580, 333147, 334267, 339029 Fax (0331)-339029 Lembar Fakultas
Jember (68121)

PERMOHONAN PANGAJUAN UJIAN SUSULAN

Nomor ...................................... Tanggal ....................

Yang bertandatangan dibawah ini :

Nama : ........................................................
NIM : ........................................................
Fakultas : ........................................................
Jurusan/Program Studi : ........................................................
Alasan : ........................................................
........................................................
........................................................

mengajukan permohonan mengikuti ujian susulan :

Matakuliah : ........................................................
Nama Dosen : ........................................................
Hari/Tanggal Ujian : ........................................................
Ruangan : ........................................................

Pemohon,

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

Diketahui, tanggal ...........................

Ketua Jurusan,
Nilai Ujian : ................. (.........)
Tanggal : ...........................
(.....................................................)
Menyetujui,tanggal .........................
NIP.
Dosen Pengampu,
Diketahui, tanggal ......................
Dekan/Pembantu Dekan I,

(.................................................)
NIP
(.................................................)
NIP.
KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN No. Form
UNIVERSITAS JEMBER F1 US010710001
Jl. Kalimantan 37 Kampus Tegal Boto Kotak Pos 159
Telp. (0331)-330224, 336579, 336580, 333147, 334267, 339029 Fax (0331)-339029 Lembar Jurusan
Jember (68121)

PERMOHONAN PANGAJUAN UJIAN SUSULAN

Nomor ...................................... Tanggal ....................

Yang bertandatangan dibawah ini :

Nama : ........................................................
NIM : ........................................................
Fakultas : ........................................................
Jurusan/Program Studi : ........................................................
Alasan : ........................................................
........................................................
........................................................

mengajukan permohonan mengikuti ujian susulan :

Matakuliah : ........................................................
Nama Dosen : ........................................................
Hari/Tanggal Ujian : ........................................................
Ruangan : ........................................................

Pemohon,

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

Diketahui, tanggal ...........................

Ketua Jurusan,
Nilai Ujian : ................. (.........)
Tanggal : ...........................
(.....................................................)
Menyetujui,tanggal .........................
NIP.
Dosen Pengampu,
Diketahui, tanggal ......................
Dekan/Pembantu Dekan I,

(.................................................)
NIP
(.................................................)
NIP.
KEMENTERIAN PENDIDIKAN KEBUDAYAAN No. Form
UNIVERSITAS JEMBER F1 US010710001
Jl. Kalimantan 37 Kampus Tegal Boto Kotak Pos 159
Telp. (0331)-330224, 336579, 336580, 333147, 334267, 339029 Fax (0331)-339029 Lembar Mahasiswa
Jember (68121)

PERMOHONAN PANGAJUAN UJIAN SUSULAN

Nomor ...................................... Tanggal ....................

Yang bertandatangan dibawah ini :

Nama : ........................................................
NIM : ........................................................
Fakultas : ........................................................
Jurusan/Program Studi : ........................................................
Alasan : ........................................................
........................................................
........................................................

mengajukan permohonan mengikuti ujian susulan :

Matakuliah : ........................................................
Nama Dosen : ........................................................
Hari/Tanggal Ujian : ........................................................
Ruangan : ........................................................

Pemohon,

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

Diketahui, tanggal ...........................

Ketua Jurusan,
Nilai Ujian : ................. (.........)
Tanggal : ...........................
(.....................................................)
Menyetujui,tanggal .........................
NIP.
Dosen Pengampu,
Diketahui, tanggal ......................
Dekan/Pembantu Dekan I,

(.................................................)
NIP
(.................................................)
NIP.