Surat Pernyataan Kesanggupan, Blokir, Biodata

SURAT PERNYATAAN
Yang bertanda tangan di bawah ini:
1.

Nama

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

2.

NIM

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

3.

Fakultas/Jurusan

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

4.

Jabatan

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

5.

Anggota

: 1. .......................................................................................................................
2. ......................................................................................................................
3. ......................................................................................................................

6.

Judul Penelitian

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

...............................................................................................................................................................................

...............................................................................................................................................................................
7. Jenis Penelitian

: Mahasiswa

8.

: Rp 5.000.000,00

Jumlah dana

Dengan ini menyatakan apabila sampai dengan batas waktu penyerahan laporan
akhir hasil penelitian beserta kelengkapannya sesuai dengan yang telah ditetapkan dalam
SPK Unesa kami belum juga menyerahkan data tersebut, maka kami bersedia sisa dana
pengabdian 30% TIDAK DICAIRKAN (DI BLOKIR) dan membayar denda sesuai
dengan SPK.
Demikian surat pernyataan ini kami buat dengan sebenarnya
Surabaya, .....................................
Yang Membuat Pernyataan,

Materai Rp 6.000,…………………………….............

SURAT PERNYATAAN KESANGGUPAN PENELITIAN
Yang bertanda tangan di bawah ini:
1. Nama

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

2. NIM

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

3. Fakultas/Jurusan

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

4. Jabatan

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

5. Anggota

: 1. ....................................................................................................................
2. ....................................................................................................................
3. ....................................................................................................................

6. Judul Penelitian

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

7. Jenis Penelitian

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

8. Jumlah dana

: Rp. 5.000.000,00

Dengan ini menyatakan kesanggupan sebagai berikut:
1. Melakukan penelitian sebagaimana judul di atas.
2. Bersifat original dan belum dibiayai oleh Lembaga/sumber dana lain.
3. Membuat laporan kemajuan, logbook, dan laporan hasil penelitian sebagaimana yang
diatur dalam surat perjanjian pelaksanaan penelitian dana DRPM tahun anggaran
2017, Nomor: ………../UN38.9/LT/2017 tanggal ……………………………… atau Nomor:
………../UN38.9/PM/2017 tanggal........................................
4. Mempertanggungjawabkan penggunaan dana penelitian sebagaimana diatur dalam
undang-undang atau peraturan yang berlaku.
5. Memberikan laporan secara berkala terkait kewajiban peneliti untuk mengupayakan
hasil laporan pengabdian dapat dimuat dijurnal internasional, hak paten hasil
penelitian, temuan teknologi tepat guna (TTG), dan buku ajar kepada Lembaga
Penelitian dan Pengabdian kepada Masyarakat Unesa.
6. Menyelesaikan semua kewajiban penelitian sesuai jadwal yang ditentukan.
7. Ijazah ditahan di BAAK apabila tidak menyelesaikan semua kewajiban penelitian dan
akan diberikan jika sudah menyelesaikannya.
Demikian surat pernyataan ini saya buat dengan sebenarnya
Surabaya,
Yang Membuat Pernyataan
Rp. 6000,..........................................................

BIODATA

PENELITIAN

Jenis Penelitian

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

Judul Penelitian

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

Kata Kunci

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

Produk/Luaran

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

Nama Ketua Penelitian

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

NIM

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

Fakultas/Jurusan

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

Alamat rumah

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

No.Telp/HP

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

Nama Anggota 1 Penelitian

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

NIM

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

Fak/Jurusan

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

Alamat rumah

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

No.Telp/HP

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

Nama Anggota 2 Penelitian

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

NIM

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

Fak/Jurusan

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

Alamat rumah

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

No.Telp/HP

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

Nama Anggota 3 Penelitian

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

NIM

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

Fak/Jurusan

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

Alamat rumah

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

No.Telp/HP

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

Dana yang diusulkan

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

Dana disetujui

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

Jangka waktu Penelitian

: ...........................................................................................................................
Surabaya,
Peneliti,

...........................................................