2017-04-06 Formulir 3 Yudisium Jurusan
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
Form 3
SURAT KETERANGAN BEBAS PINJAM FASILITAS
FACILITIES INDEBTEDNESS FREE FORM
Dengan ini menerangkan bahwa mahasiswa S-1/S-2di bawah ini :
The undersigned below hereby certifies that the following Undergraduate/Master
Nama
Name
NIM
Student No.
: ……………………………………………………………………………………………….……………………
: ………………………………………………………………………………………………...….……………….
Telah bebas pinjam fasilitas Perpustakaan, Laboratorium dan Bagian Sarana Prasarana DepartemenTeknik Geologi, Fakultas Teknik, UGM.
Do not have any indebtedness of facility at the library, laboratory and general facility unit in Department of Geological Engineering Department,
Faculty of Engineering, UGM.
No.
1.
2.
Tanggal
(Date)
Unit Pelayanan Fasilitas
(Service Fasilities Unit)
Perpustakaan
(Library)
Sarana Prasarana
(General facility service unit)
3.
Sedimentografi
(Sedimentography Lab.)
4.
Geologi Tata Lingkungan
(Environmental Geology Lab.)
5.
Geofisika Eksplorasi
(Exploration Geophysics Lab.)
6.
Bahan Galian
(Mineral Resource Lab.)
Paleontologi
(Paleontology Lab.)
Geologi Dinamik
(Dynamics Geology Lab.)
Geo Optik
(Optical Geology Lab.)
Geokimia
(Geochemistry Lab.)
Pusat Geologi
(Central Geology Lab.)
7.
8.
9.
10.
11.
No. Agenda
Seksi/Lab
Nama Petugas
(Officer Name)
Tanda Tangan
(Signature)
1
2
3
4
5
6
7
8
9
10
11
Keterangan ini diberikan untuk memenuhi persyaratan yudisium sarjana/pascasarjana di Departemen Teknik Geologi FT. UGM. Apabila di
kemudian hari ternyata ada kesalahan maka surat keterangan ini akan ditinjau kembali.
This information is given to meet the requirements of graduation judicium in Department of Engineering Geology FT. Should there be any revision,
this certificate will be reviewed.
Yogyakarta, ……………………………….
Mengetahui,
Acknowledged,
Kepala Unit Pengembangan SDM, Aset, Sistem Informasi dan SHE
(Head of Unit of Human Resources Development, Asset, Information
System and SHE)
( ………………………………………)
NIP.
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
Form 3
SURAT KETERANGAN BEBAS PINJAM FASILITAS
FACILITIES INDEBTEDNESS FREE FORM
Dengan ini menerangkan bahwa mahasiswa S-1/S-2di bawah ini :
The undersigned below hereby certifies that the following Undergraduate/Master
Nama
Name
NIM
Student No.
: ……………………………………………………………………………………………….……………………
: ………………………………………………………………………………………………...….……………….
Telah bebas pinjam fasilitas Perpustakaan, Laboratorium dan Bagian Sarana Prasarana DepartemenTeknik Geologi, Fakultas Teknik, UGM.
Do not have any indebtedness of facility at the library, laboratory and general facility unit in Department of Geological Engineering Department,
Faculty of Engineering, UGM.
No.
1.
2.
Tanggal
(Date)
Unit Pelayanan Fasilitas
(Service Fasilities Unit)
Perpustakaan
(Library)
Sarana Prasarana
(General facility service unit)
3.
Sedimentografi
(Sedimentography Lab.)
4.
Geologi Tata Lingkungan
(Environmental Geology Lab.)
5.
Geofisika Eksplorasi
(Exploration Geophysics Lab.)
6.
Bahan Galian
(Mineral Resource Lab.)
Paleontologi
(Paleontology Lab.)
Geologi Dinamik
(Dynamics Geology Lab.)
Geo Optik
(Optical Geology Lab.)
Geokimia
(Geochemistry Lab.)
Pusat Geologi
(Central Geology Lab.)
7.
8.
9.
10.
11.
No. Agenda
Seksi/Lab
Nama Petugas
(Officer Name)
Tanda Tangan
(Signature)
1
2
3
4
5
6
7
8
9
10
11
Keterangan ini diberikan untuk memenuhi persyaratan yudisium sarjana/pascasarjana di Departemen Teknik Geologi FT. UGM. Apabila di
kemudian hari ternyata ada kesalahan maka surat keterangan ini akan ditinjau kembali.
This information is given to meet the requirements of graduation judicium in Department of Engineering Geology FT. Should there be any revision,
this certificate will be reviewed.
Yogyakarta, ……………………………….
Mengetahui,
Acknowledged,
Kepala Unit Pengembangan SDM, Aset, Sistem Informasi dan SHE
(Head of Unit of Human Resources Development, Asset, Information
System and SHE)
( ………………………………………)
NIP.