Hal : Permohonan Pindah Studi / Mengundurkan Diri

Yth. Rektor
U.b. Direktur Pendidikan
Universitas Airlangga
Surabaya

Dengan hormat,

Yang bertanda tangan di bawah ini, kami:

Nama : ............................................................................................................................
NIM : ............................................................................................................................
Fakultas : ............................................................................................................................
Program Studi : ............................................................................................................................
Alamat : ............................................................................................................................
...........................................................................................................................
No. Telepon: ........................................................................................................

Dengan ini kami mengajukan permohonan Pindah Studi / Mengundurkan Diri dari
Fakultas ....................................................................................................................................U
niversitas Airlangga Semester Gasal / Genap Tahun
Akademik ................................../..........................
Adapun alasan kami mengajukan permohonan pindah studi / mengundurkan diri tersebut,
karena .........................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Demikian permohonan kami, atas perhatian Bapak Rektor kami sampaikan terima kasih.

No............................................................... Banyuwangi,
........................................................
Menyetujui, Pemohon
Pimpinan Fakultas,