Hal : Permohonan Penggantian ..............................

Jadwal Ujian Tesis

Yth. Wakil Dekan I

Fakultas Kesehatan Masyarakat
Universitas Airlangga
Surabaya

Dengan ini kami mohon penggantian jadwal ujian Tesis atas nama :

Nama : ............................................................................................................................
NIM : ............................................................................................................................
Minat : ............................................................................................................................
Judul : ............................................................................................................................

mohon penggantian jadwal ujian Tesis yang semula :

Tanggal : ............................................................................................................................

Diganti pada :
Tanggal : ............................................................................................................................
Dengan alasan : ............................................................................................................................

Atas perhatian dan bantuannya kami sampaikan terima kasih.

Pembimbing Ketua Pemohon

............................................ ............................................
NIP. NIM.

Mengetahui
Ketua Minat Studi ........................

......................................................
NIP.