UNIVERSITAS BRAWIJAYA
FAKULTAS ILMU SOSIAL DAN ILMU POLITIK
Jalan Veteran, Malang, 65145, Indonesia
Telp. :+62341 575755; Fax : +62-341-570038
Website: www.fisip.ub.ac.id Email: fisip@ub.ac.id
NAMA : ...........................................................................................................
NIM/NIP/NIK : ...........................................................................................................
JURUSAN/PRODI : ...........................................................................................................
EMAIL : ...........................................................................................................
NO.HP : ...........................................................................................................
NAMA DOSEN PEMBIMBING : 1. .......................................................................................................
2. .......................................................................................................
EMAIL DOSEN PEMBIMBING*: 1. .......................................................................................................
2. .......................................................................................................
JUDUL KARYA ILMIAH/ SKRIPSI/ TESIS/DISERTASI/ LAPORAN PENELITIAN/ LAPORAN
PENGABDIAN:
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
OPERATOR PEMOHON
*email dapat diisi kedua dosen pembimbing atau salah satu dosen pembimbing (khusus untuk
Skripsi, Tesis dan Disertasi)