SURAT PERNYATAAN BLOKIR

SURAT PERNYATAAN
Yang bertanda tangan di bawah ini:
1.

Nama

: …………………………………………………………………..

2.

NIP

: …………………………………………………………………..

3.

Fakultas/Jurusan

: …………………………………………………………………..

4.

Jabatan

:

…………………………………………………………………..
5.

Anggota

: 1. ……………………………………………………………….
2. ……………………………………………………………….
3. ……………………………………………………………….

6.

Judul Pengabdian/Penelitian :
………………………………………………………………................................
…………………………………………………………………..............................
………………………………………………………………….............................

7.

Jenis Pengabdian/Penelitian
: ................................................................................................

8.

Jumlah dana

: Rp ................................................................................................

Dengan ini menyatakan apabila sampai dengan batas waktu penyerahan laporan akhir
hasil pengabdian beserta kelengkapannya sesuai dengan yang telah ditetapkan dalam SPK
Unesa kami belum juga menyerahkan data tersebut, maka kami bersedia sisa dana pengabdian
30% TIDAK DICAIRKAN (DI BLOKIR) dan membayar denda sesuai dengan SPK.
Demikian surat pernyataan ini kami buat dengan sebenarnya
Surabaya, .....................................
Yang Membuat Pernyataan,

Materai Rp 6.000,-

…………………………….............
NIP

SURAT PERNYATAAN KESANGGUPAN PENELITIAN/PKM
Yang bertanda tangan di bawah ini:
1.
2.

Nama
NIP

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

3.

Fakultas/Jur

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

4.

Jabatan

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

5.

Anggota

: 1. .......................................................................................................
2. .......................................................................................................
3. ........................................................................................................

6. Judul Penelitian/Pengabdian

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

..........................................................................................................
..........................................................................................................
7. Jenis Penelitian/Pengabdian
8.

Jumlah dana

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

: Rp. ..................................................................................................

Dengan ini menyatakan kesanggupan sebagai berikut:
1. Melakukan penelitian/PKM sebagaimana judul di atas.
2. Bersifat original dan belum dibiayai oleh Lembaga/sumber dana lain.
3. Membuat laporan kemajuan, logbook, dan laporan hasil penelitian/ PKM sebagaimana
yang diatur dalam surat perjanjian pelaksanaan penelitian/ PKM dana DRPM tahun
anggaran 2017, Nomor: ………../UN38.9/LT/2017 tanggal ……………………………… atau
Nomor: ………../UN38.9/PM/2017 tanggal........................................
4. Mempertanggungjawabkan penggunaan dana penelitian/ PKM sebagaimana diatur
dalam undang-undang atau peraturan yang berlaku.

5. Memberikan laporan secara berkala terkait kewajiban peneliti untuk mengupayakan
hasil laporan pengabdian dapat dimuat dijurnal internasional, hak paten hasil
penelitian, temuan teknologi tepat guna (TTG), dan buku ajar kepada Lembaga
Penelitian dan Pengabdian kepada Masyarakat Unesa.
6. Menyelesaikan semua kewajiban penelitian/ PKM sesuai jadwal yang ditentukan.
Demikian surat pernyataan ini saya buat dengan sebenarnya
Surabaya,
Yang Membuat Pernyataan

Rp. 6000,..........................................................
NIP
BIODATA PENELITIAN/PKM

Jenis Penelitian/PKM
Judul Penelitian/PKM

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

Kata Kunci
: ............................................................................................................................
Produk/Luaran
: ............................................................................................................................
Nama Ketua Penelitian/PKM
: ............................................................................................................................
NIP
: ............................................................................................................................
NIDN
: ............................................................................................................................
Pendidikan/Gol.
: ............................................................................................................................
Fak/Jurusan
: ............................................................................................................................
Alamat rumah
: ............................................................................................................................
No.Telp/HP
: ............................................................................................................................
Nama Anggota 1 Penelitian/PKM : ............................................................................................................................
NIP

: ............................................................................................................................
NIDN
: ............................................................................................................................
Pendidikan/Gol.
: ............................................................................................................................
Fak/Jurusan
: ............................................................................................................................
Alamat rumah
: ............................................................................................................................
No.Telp/HP
: ............................................................................................................................
Nama Anggota 2 Penelitian/PKM : ............................................................................................................................
NIP
: ............................................................................................................................
NIDN
: ............................................................................................................................
Pendidikan/Gol.
: ............................................................................................................................
Fak/Jurusan
: ............................................................................................................................

Alamat rumah
: ............................................................................................................................
No.Telp/HP
: ............................................................................................................................
Nama Anggota 3 Penelitian/PKM : ............................................................................................................................
NIP
: ............................................................................................................................
NIDN
: ............................................................................................................................
Pendidikan/Gol.
: ............................................................................................................................
Fak/Jurusan
: ............................................................................................................................
Alamat rumah
: ............................................................................................................................
No.Telp/HP
: ............................................................................................................................
Dana yang diusulkan
: ............................................................................................................................
Dana disetujui

: ............................................................................................................................
Jangka waktu Penelitian/PKM
: ...........................................................................................................................
Surabaya,
Peneliti/Pelaksana,

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