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~ FORMULIR PERMOHONAN ~

1. Keperluan permohonan : Rekomendasi penelitian dosen/ Skripsi/ Tesis/ Disertasi/ Mata Kuliah/ KTI/ PKM.
Rekomendasi PKL/ PKN/ Magang/ Pengabdian Masyarakat/ Prakerin.
(lingkari sesuai keperluan)
2. Identitas pemohon

- nama : ...........................................................................

- alamat : ........................................................................... (di malang)

- telpon / HP : ...........................................................................

- Fak/ Univ./ Lembaga : ...........................................................................

3. Lokasi / tujuan : 1) ..............................................................................................................

Kegiatan 2) ..............................................................................................................

3) ..............................................................................................................

4) ..............................................................................................................

4. Waktu kegiatan : .................................................. s/d .......... ..............................................

5. Tema / judul : ...................................................................................................................

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

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

6. Jumlah peserta : ............orang

7. Dosen pembimbing : 1) ..............................................................................................................

2) ..............................................................................................................

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Berkas diterima, No. Register :

tanggal ......................................................... , jam .................... WIB

PETUGAS PEMOHON

(...................................................................) (.................................................................)

Kelengkapan yang kurang : Fc. KTP/ Materai/ Proposal/ Lampiran Peserta/ Legalitas Kampus.

Tahun 2017

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