OLEH
NAMA MAHASISWA :
NIM :
BIDANG PKP :
LOKASI :
BIDANG PKMI.....................................................
NAMA : ..............................................
NIM : ..............................................
LOKASI PKMI : ..............................................
NAMA : ..............................................
NIM : ..............................................
LOKASI PKPM : ..............................................
WAKTU PELAKSANAAN : ..............................................
...................................... 20...
Disetujui Oleh :
Nama Nama
------------------------- ----------------------------
Nama Nama
------------------------ -------------------------
Nip. ……………. Nip………………..
DATA MAHASISWA
1. Nama : .............................................................
2. Jenis Kelamin : .............................................................
3. Tempat/Tgl Lahir : .............................................................
4. Agama : .............................................................
5. Alamat Rumah/Tlp : .............................................................
.............................................................
.............................................................
6. No Kartu Penduduk : .............................................................
7. No Kartu Mahasiswa : .............................................................
8. Golongan Darah : .............................................................
9. Bila terjadi sesuatu, dapat dihubungi :
A. 01. Nama : .............................................................
02. Alamat/Tlp : ............................................................
............................................................
Tujuan Pelaksanaan :
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
............................................................
Daftar Pustaka :
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
................................................
.....................................................................................................
............
Tanggal Pelaksanaan Kegiatan,
.....................................
Tanda tangan Pembimbing Lapangan
(.........................................................)