Document Akademik POLINDRA | Politeknik Negeri Indramayu FORM BEBAS MASALAH
BIODATA ALUMNI
Nama
: ...........................................................................................................
NPM
: ...........................................................................................................
Jurusan/ Program Studi
: ...........................................................................................................
Tempat Tanggal lahir
: ...........................................................................................................
Jenis Kelamin
: laki –laki / Perempuan
Golongan Darah
: ...........................................................................................................
Judul Tugas Akhir
: ...........................................................................................................
...........................................................................................................
Indeks Prestasi Kumulatif
: ...........................................................................................................
Alamat Mahasiswa
: ...........................................................................................................
...........................................................................................................
No. Telephone
: ...........................................................................................................
Handphone
: ...........................................................................................................
Email
: ...........................................................................................................
Nama Orang Tua/Wali
: ...........................................................................................................
Pekerjaan
: ...........................................................................................................
Alamat Orang Tua
: ...........................................................................................................
...........................................................................................................
Tahun Akademik/
: ...........................................................................................................
Periode Wisuda
Indramayu, ........................................
Alumni,
Foto
3x4
............................................................
NPM.
B A K POLITEKNIK NEGERI INDRAMAYU
FORM BEBAS MASALAH ADMINISTRASI PUSAT
Nama
: ...........................................................................................................
NPM
: ...........................................................................................................
Jurusan/ Program Studi : TEKNIK MESIN/ TEKNIK PENDINGIN DAN TATA UDARA/TEKNIK INFORMATIKA)*
NO
1.
BAGIAN
BAGIAN
KEUANGAN
2.
UPT
PERPUSTAKAAN
3.
JURUSAN/ PRODI
PENANGGUNG
JAWAB
TANDA
TANGAN DAN
NAMA JELAS
CATATAN
Ka.Subbag
Keuangan
Ka.UPT
Perpustakaan
Ka.Jurusan
/Ka.Prodi
)* Coret yang tidak perlu
Catatan :
1. Sah apabila ada stempel setiap bagian
2. Melampirkan bukti penyerahan laporan dan CD Tugas Akhir serta Laporan dan CD PPI di
perpustakaan
3. Melampirkan form bebas masalah jurusan yang sudah ditandatangani Kajur
B A K POLITEKNIK NEGERI INDRAMAYU
FORM BEBAS MASALAH ADMINISTRASI JURUSAN
Nama
: ...........................................................................................................
NPM
: ...........................................................................................................
Jurusan/ Program Studi : TEKNIK MESIN/ TEKNIK PENDINGIN DAN TATA UDARA/TEKNIK INFORMATIKA)*
NO
JENIS KEGIATAN
1.
Pengumpulan CD
dan Laporan TA
2.
Pengumpulan CD
dan Laporan PPI
3.
Bebas Masalah
Laboratorium
Jurusan/Prodi
4.
Bebas Kompensasi
Jurusan/Prodi
PENANGGUNG
JAWAB
TANDA
TANGAN DAN
NAMA JELAS
CATATAN
Administrasi
Jurusan/Prodi
Administrasi
Jurusan/Prodi
Kepala
Laboratorium
Ka.Jurusan
/Sekretaris
Jurusan
)* Coret yang tidak perlu
Indramayu, ........................................
Ketua Jurusan,
_________________________
NIK.
Nama
: ...........................................................................................................
NPM
: ...........................................................................................................
Jurusan/ Program Studi
: ...........................................................................................................
Tempat Tanggal lahir
: ...........................................................................................................
Jenis Kelamin
: laki –laki / Perempuan
Golongan Darah
: ...........................................................................................................
Judul Tugas Akhir
: ...........................................................................................................
...........................................................................................................
Indeks Prestasi Kumulatif
: ...........................................................................................................
Alamat Mahasiswa
: ...........................................................................................................
...........................................................................................................
No. Telephone
: ...........................................................................................................
Handphone
: ...........................................................................................................
: ...........................................................................................................
Nama Orang Tua/Wali
: ...........................................................................................................
Pekerjaan
: ...........................................................................................................
Alamat Orang Tua
: ...........................................................................................................
...........................................................................................................
Tahun Akademik/
: ...........................................................................................................
Periode Wisuda
Indramayu, ........................................
Alumni,
Foto
3x4
............................................................
NPM.
B A K POLITEKNIK NEGERI INDRAMAYU
FORM BEBAS MASALAH ADMINISTRASI PUSAT
Nama
: ...........................................................................................................
NPM
: ...........................................................................................................
Jurusan/ Program Studi : TEKNIK MESIN/ TEKNIK PENDINGIN DAN TATA UDARA/TEKNIK INFORMATIKA)*
NO
1.
BAGIAN
BAGIAN
KEUANGAN
2.
UPT
PERPUSTAKAAN
3.
JURUSAN/ PRODI
PENANGGUNG
JAWAB
TANDA
TANGAN DAN
NAMA JELAS
CATATAN
Ka.Subbag
Keuangan
Ka.UPT
Perpustakaan
Ka.Jurusan
/Ka.Prodi
)* Coret yang tidak perlu
Catatan :
1. Sah apabila ada stempel setiap bagian
2. Melampirkan bukti penyerahan laporan dan CD Tugas Akhir serta Laporan dan CD PPI di
perpustakaan
3. Melampirkan form bebas masalah jurusan yang sudah ditandatangani Kajur
B A K POLITEKNIK NEGERI INDRAMAYU
FORM BEBAS MASALAH ADMINISTRASI JURUSAN
Nama
: ...........................................................................................................
NPM
: ...........................................................................................................
Jurusan/ Program Studi : TEKNIK MESIN/ TEKNIK PENDINGIN DAN TATA UDARA/TEKNIK INFORMATIKA)*
NO
JENIS KEGIATAN
1.
Pengumpulan CD
dan Laporan TA
2.
Pengumpulan CD
dan Laporan PPI
3.
Bebas Masalah
Laboratorium
Jurusan/Prodi
4.
Bebas Kompensasi
Jurusan/Prodi
PENANGGUNG
JAWAB
TANDA
TANGAN DAN
NAMA JELAS
CATATAN
Administrasi
Jurusan/Prodi
Administrasi
Jurusan/Prodi
Kepala
Laboratorium
Ka.Jurusan
/Sekretaris
Jurusan
)* Coret yang tidak perlu
Indramayu, ........................................
Ketua Jurusan,
_________________________
NIK.