FORMULIR PESERTA WISUDA

Nama Lengkap (dengan gelar) : ......................................................................................................................

Tempat, Tanggal Lahir : ......................................................................................................................

Nomor Pokok Mahasiswa (NPM) : ......................................................................................................................

Jenis Kelamin : ......................................................................................................................

Agama : ......................................................................................................................

Alamat Rumah : ......................................................................................................................

Nomor : 1. Ponsel/Handphone : ......................................................................................................................

2. Telepon Rumah : ......................................................................................................................

3. Telepon Kantor : ......................................................................................................................

Pekerjaan : ......................................................................................................................

Jabatan : ......................................................................................................................

Instansi/Institusi : ......................................................................................................................

Alamat Kantor : ......................................................................................................................

Program Studi : Magister Ilmu Administrasi

Konsentrasi / Peminatan : ......................................................................................................................

Tanggal Lulus / Yudisium : ......................................................................................................................

Predikat Kelulusan : ......................................................................................................................

Nomor Alumni (Diisi Panitia) : ......................................................................................................................

Judul Tesis : ......................................................................................................................

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

Komisi Penasehat : 1. ................................................................................................................

2. ................................................................................................................

Foto Warna
(4 X 6) Gorontalo, ......................................................
Yang Membuat,

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

FORMULIR PENGUSULAN
 IJAZAH MAGISTER ILMU ADMINISTRASI
Nama Lengkap (dengan gelar) : ......................................................................................................................

Tempat, Tanggal Lahir : ......................................................................................................................

Nomor Pokok Mahasiswa (NPM) : ......................................................................................................................

Program Studi : Magister Ilmu Administrasi

Konsentrasi / Peminatan : ......................................................................................................................

Tanggal Lulus / Yudisium : ......................................................................................................................

Predikat Kelulusan : ......................................................................................................................

Nomor Alumni (Diisi Panitia) : ......................................................................................................................

Judul Tesis : ......................................................................................................................

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

Komisi Penasehat : 1. ................................................................................................................

2. ................................................................................................................

Nomor HP/Rumah/Kantor : ......................................................................................................................

Alamat Rumah : ......................................................................................................................

Pekerjaan : ......................................................................................................................

Jabatan : ......................................................................................................................

Instansi/Institusi : ......................................................................................................................

Alamat Kantor : ......................................................................................................................

Disetujui, Gorontalo, ........................................................................

Ketua Program Studi Diusulkan oleh
Magister Ilmu Administrasi

Dr. Sudarsono, MM ...........................................................................

NIDN. 0915077903
Mengetahui,
Asisten Direktur I

Djamila Podungge, S.SI., M.Si

NIDN. 0901039003
 LAMPIRAN: PAS FOTO

Foto Warna Foto Warna

(4 X 6) (4 X 6)

Foto Hitam Putih Foto Hitam Putih

(4 X 6) (4 X 6)

Catatan:
1. Pas foto terbaru atau 3 (tiga) bulan terakhir
2. Menggunakan pakaian Toga Wisuda
3. Foto warna 2 (dua) lembar ukuran 4 x 6 cm
4. Foto hitam putih 2 (dua) lembar ukuran 4 x 6 cm
5. Fotokopi Ijazah Strata Satu (S1) yang telah dilegalisir
6. Fotokopi KTP