:....................................................................................................................
:....................................................................................................................
:....................................................................................................................
2. Data Penelitian
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c. Alamat/email :....................................................................................................................
d. Institusi :...................................................................................................................
6. Lokasi Penelitian
b. Bangsal/Ruang :...................................................................................................................
7. Kesediaan : YA / TIDAK
a. Catatan :...................................................................................................................
:....................................................................................................................
:....................................................................................................................
Palembang,
Mengetahui
Kepala Instalasi/Bagian/Ruang.......................................
Nama.............................................................................
NIP.................................................................................