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NIM :………………………………………………………………….......
Program studi :………………………………………………………………….......
Alamat : ………………………………………………………………….......
: RT....... RW ........
Desa/Kelurahan :………………………………………………………………...........
Kecamatan :………………………………………………………………….......
Kab./Kota : ………………………………………………………………….......
HASIL SURVEY/OBSERVASI LAPANGAN:
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PERMASALAHAN YANG DITEMUKAN:
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RENCANA PROGRAM YANG AKAN DILAKSANAKAN:
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Tanda Tangan
Dan Cap Basah
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Menyetujui:
Dosen Pembimbing Lapangan
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