KEMENTERIAN AGAMA REPUBLIK INDONESIA

INSTITUT AGAMA ISLAM NEGERI TULUNGAGUNG

FAKULTAS EKONOMI DAN BISNIS ISLAM
Jalan Mayor Sujadi Timur Nomor 46 Tulungagung - Jawa Timur 66221
Telepon (0355) 321513, 321656 Faximile (0355) 321656
Website : http://iain-tulungagung.ac.id

FORMULIR PENDAFTARAN UJIAN SKRIPSI

FAKULTAS EKONOMI DAN BISNIS ISLAM

Nama lengkap (sesuai ijazah) : ..................................................................................................................

NIM : ..................................................................................................................
Jurusan/Prodi : ..................................................................................................................
Jenis Kelamin : ..................................................................................................................
Tempat, tanggal lahir : ..................................................................................................................
Nomor HP : ..................................................................................................................
Alamat Tinggal Lengkap : ..................................................................................................................
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Nama Orang Tua
Ayah : ..................................................................................................................
Ibu : ..................................................................................................................
Pekerjaan Orang Tua
Ayah : ..................................................................................................................
Ibu : ..................................................................................................................
Nama Wali (jika ikut wali) : ..................................................................................................................
Judul Skripsi : ..................................................................................................................
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Dosen Pembimbing : ..................................................................................................................
Pendidikan terakhir sebelum masuk IAIN: MA / SMA / SMK / ................................................... (namanya)
Di : ..................................................................................................................
Tahun Masuk IAIN : ..................................................................................................................
IP Sementara : ..................................................................................................................
Jumlah sks yang diambil (termasuk skripsi) : .........................................................................................

Pemohon,

NIM.

Mengetahui,
Wali Studi Pembimbing

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NIP. NIP.