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KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS LAMPUNG FAKULTAS PERTANIAN


JURUSAN TEKNIK PERTANIAN
Jl. Prof. Dr. Sumantri Brodjonegoro No. 1 Bandar Lampung 35145
Telp. (0721) 704946 Fax. (0721) 770347
Gedung H Jurusan Teknik Pertanian Fakultas Pertanian Universitas Lampung

FORMULIR PENDAFTARAN PRAKTIK UMUM TH.2021

Nama Mahasiswa : .....................................................................................................


NPM : .....................................................................................................
Jenis kelamin : .....................................................................................................
No.HP : .....................................................................................................
Minat studi : A (DAMP) / B (RSDAL) / C (RBPP)
Judul (Rencana) : .....................................................................................................
Judul : .....................................................................................................
Jumlah SKS (Lampirkan Transkrip sampai Smt 4 & KRS Smt-5) : ................................
Nama orang tua : ....................................................................................................
Alamat orang tua : ....................................................................................................
Lokasi PU : .....................................................................................................
Alamat Lokasi PU : .....................................................................................................
Alamat : .....................................................................................................
Dosen Pemb.Akademik ......................................................................................................:
Anggota Kelompok (jika ada) :
: 1. ..................................................................................................
: 2. ..................................................................................................
: 3. ..................................................................................................
: 4. ..................................................................................................
: 5. ..................................................................................................

Bandar Lampung, Februari 2021

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NPM

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