form isian kontrak Stimulus

FORMULIR ISIAN
USULAN BANTUAN STIMULUS BAGI PERGURUAN TINGGI
TAHUN 2013
I.

Pejabat yang menandatangani Surat Perjanjian Pelaksanaan Kegiatan/Kontrak:
a. Nama

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

b. NIP

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

c. Jabatan

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

d. Institusi

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

e. Alamat Kantor

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

f.

II.

Telp/Faks Kantor

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

g. HP

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

h. Email

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

Data Perbankan (Harus Rek.Institusi bukan Rek.Pribadi):
a. Nama Bank

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

b. Alamat Bank

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

c. Nomor Rekening

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

d. Atas Nama

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

(lampirkan fotocopy rekening koran yang disyahkan/legalisir bank)
e. Nomor NPWP

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

(lampirkan fotocopy NPWP)
.............................,................................2013

Cap/stempel
.................................................................
Nama pejabat yang berwenang menandatangani Surat perjanjian
Catatan:
1. Kesalahan mengisi akan berakibat terlambat/tidak dapat diproses pencairan dananya
(Keterlambatan pencairan akibat kesalahan tersebut bukan tanggungjawab Ditjen Dikti);
2. Tidak diperkenankan mengganti formulir ini;
3. Untuk informasi hubungi 021-57946100 ext.0444.