Tawaran Program SAME Tahun 2017 FORM SAME B

DIRECTORATE OF CAREER AND COMPETENCY OF HUMAN RESOURCES
DIRECTORATE GENERAL OF RESOURCES OF SCIENCE, TECHNOLOGY AND
HIGHER EDUCATION
MINISTRY OF RESEARCH, TECHNOLOGY AND HIGHER EDUCATION
FORM SAME-B
A. PERSON IN CHARGE
1. Full name (capital
: ............................... ..............................................
letters)
.........
(First name)
(Last name)
2. Gender
:  Male
 Female
3. Place & date of birth : .............................................., ......./.........................
..../.........
4. Home address &
: .................................................................................
Phone No.
.................

.................................................................................
................
................................................... Post
code : ..............................
Tel. : (..........)..........................
Mobile : ....................................
5. E-mail address
6. Host Institution :
University

: .................................................................................
..................
: .................................................................................
..................

Faculty

: .................................................................................
..................

Department

: .................................................................................
..................

7. Civil service data

: NIP : ...............
.....
NIDN : .............
(if available)
....

8. Rank (Golongan)

: ...............................................

B.
1.
2.

3.

INVITEE
Name
Institution
Expertise

Karpeg. ..............
.......
(if available)

:
:
:

Verified by Rector

Date : ...................................................
Signature of Person in Charge

1

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

2

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