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BLANGKO SURAT PERNYATAAN MASIH KULIAH

Nama : ______________________________________________________

Tempat/Tanggal Lahir : ______________________________________________________

NIM : ______________________________________________________

Jurusan : ______________________________________________________

Prodi : ______________________________________________________

Jenjang : ______________________________________________________

Semester : ______________________________________________________

No.Handphone : ______________________________________________________

Alamat : ______________________________________________________

______________________________________________________

Keperluan : ______________________________________________________

Mataram,..............................20

Pemohon.

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