YAYASAN PERGURUAN TINGGI SURAKARTA

UNIVERSITAS SURAKARTA
Kampus : Jl. Raya Palur Km 5 Surakarta (57772) Tlp. 0271 - 825117
Website : http://www.unsa.ac.id E-mail : info@unsa.ac.id

FORMULIR PENDAFTARAN WISUDA

(diisi dengan huruf TEGAK/ BALOK)
Bersama ini saya mohon dibuatkan ijazah dengan data mahasiswa sebagai berikut :
Jenjang Pendidikan : [ ] Reguler S.2 [ ] Transfer S.1 [ ] Reguler S.1

Nama Lengkap : ...........................................................................................................................................

(Sesuai ijazah terlampir)
Tempat dan Tanggal Lahir : ...........................................................................................................................................
Nomor Pokok Mahasiswa : ..................................................... Tahun Pertama Masuk : ...........................................
Fakultas : ...........................................................................................................................................
Program Studi : ...........................................................................................................................................
No. Induk Kependudukan : ...........................................................................................................................................
Tanggal, Tahun Lulus : .............................................................................. IPK : ....................................................
(sesuai dengan Tanggal Lulus Ujian Tesis/ Skripsi)
Judul Tesis/ Skripsi : ...........................................................................................................................................
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Alamat Rumah : ........................................ No.......... Rt........... Rw............ Kel .............................................
Kota : .................................................. Telp/ HP : ............................................................
Email : ...........................................................................................................................................

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

Instansi/Perusahaan : ...........................................................................................................................................

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

Kota : .................................................. Telp Kantor :..........................................................
Nama Orang Tua : Ayah :.................................................. Ibu : .....................................................................
Dokumen persyaratan yang harus dipenuhi Mahasiswa :

1. [ ] Pas Foto 3x4 Hitam putih 2 lembar

2. [ ] Fotokopi Kwitansi pembayaran wisuda dari BAKU
3. [ ] Fotokopi Surat lunas bebas keuangan dari BAKU.
4. [ ] Surat keterangan bebas administrasi prodi dan bebas perpustakaan
Formulir dikumpulkan ke Ketua Program Studi untuk diserahkan ke panitia wisuda paling lambat 23 September 2022

Surakarta, ...........................................
Mengetahui Pemohon,
Ketua Program Studi

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