FORMULIR SURAT KETERANGAN PENDAMPING IJAZAH

NAMA : ..................................................................................................

TEMPAT/TGL LAHIR : ..................................................................................................

NIM : ..................................................................................................

NO. TELP/HP : ..................................................................................................

TAHUN MASUK : ..................................................................................................

LAMA STUDI : ........................SEMESTER

KEIKUTSERTAAN
DALAM ORGANISASI : 1 ..............................................................................................

2. ……………………………………………………………………

3……………………………………………………………………..

4………………………………………………………………………

PRESTASI/PENGHARGAAN : 1 ..............................................................................................

2. ……………………………………………………………………

3……………………………………………………………………..

SERTIFIKAT KEAHLIAN : 1 ..............................................................................................

2. ……………………………………………………………………

3……………………………………………………………………..

PUBLIKASI/SEMINAR/
ORASI ILMIAH : 1 ..............................................................................................

2. ……………………………………………………………………

3……………………………………………………………………..

Bangkalan, ....................................

MAHASISWA

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

NB : UNTUK PENGHARGAAN, PRESTASI DAN SEMINAR MELAMPIRKAN SERTIFIKAT YANG DIFOTOCOPY