Formulir Permohonan Ujian S 3 final

UNIVERSITAS GADJAH MADA - FAKULTAS TEKNIK
UNIVERSITAS GADJAH MADA – FACULTY OF ENGINEERING
DEPARTEMEN TEKNIK GEOLOGI
DEPARTMENT OF GEOLOGICAL ENGINEERING
Jl.Grafika No.2 Kampus UGM, Yogyakarta 55281 Indonesia Telp. (0274) 513668 Fax (0274) 546039
Website: http://geologi.ugm.ac.id | E-mail: jtg.ft@ugm.ac.id

FORMULIR PERMOHONAN SEMINAR/KOLOKIUM/UJIAN
(Seminar/Colloquium/Examination Proposal Form)
Nama Mahasiswa
(Name)

:

___________________________________________________________

NIM
(Academic No.)

:

___________________________________________________________

Angkatan
(Academic Year)

:

___________________________________________________________

No. Telepon
Phone Number

:

___________________________________________________________

Email
Email

:

___________________________________________________________

Judul
(Title)

:

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Dosen Pembimbing Utama
(Promoter)

:

___________________________________________________________

Jenis Permohonan (Proposal Type)
:
 Ujian proposal (proposal exam)1
 Kelayakan disertasi (review of disertation) 4
Persyaratan (Requirements)

 Seminar I2
 Kelayakan/Ujian Tertutup (final exam) 5

 Seminar II3
 Ujian Terbuka (Open exam) 6

:
Aktif di semester berjalan (Active) 1,2,3,4,5,6
Sertifikat TOEFL dan TPA (Copy of TOEFL/TPA certificate) 1
Salinan kartu hasil studi (Copy of progress report) 1
Salinan log book/kartu konsultasi (Copy of log book) 1,2,3,4,5

Publikasi, terlampir (Publication, attached) 3,4,5,6
a. Prosiding seminar nasional (national conference proceedings)
b. Prosiding seminar internasional (international conference proceedings)
c. Jurnal nasional terakreditasi (national acreditated journal)
d. Jurnal internasional (international journal)
e. Jurnal internasional terindeks (indexed international journal)
6. Draf yang sudah disetujui oleh pembimbing (Approved draft) 1,2,3,4,5,6

1.
2.
3.
4.
5.

Mengetahui
Acknowledged
Pengelola
Academic Affair/Program Manager

( ………………………………………)

NIP.
Beri tanda silang atau centang pada kotak ()!

Yogyakarta, ………………………………..
Mahasiswa,
Student

( ………………………………………)
NIM.

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