Nama : ..............................................................................
NIM : ..............................................................................
Semester/Kelas : ..............................................................................
Tahun Akademik : ..............................................................................
Fakultas : ..............................................................................
Program Studi : ..............................................................................
Jumlah SKS
Pangkalanbaru,..............................
Dosen Penasehat Akademik Mahasiswa
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Ket :
Conteng Mata Kuliah Mengulang
Foto Copy Rangkap 2 (dua) :
1. Dosen Pembimbing
2. Program Studi