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.