2017-04-06 Formulir 2 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
*diisi dengan huruf balok
(filled in with capital letter)

Form 2
DATA WISUDAWAN PROGRAM STUDI S-1/S-2
GRADUATION DATA

Departemen Teknik Geologi FT UGM
Department of Geological Engineering
Faculty of Engineering, Gadjah Mada University

Periode Wisuda

: ………………………

Tahun ...……………………..

Graduation Periode

Nama

Year

: ……………………………………………………………..

Name

NIM

: ……..…..…………………………………...….…………..

Student No.

Tempat, Tgl. Lahir

: ………………………………………………….………….

Place of birth, date of birth

Terdaftar pertama kali

Foto 3 x 4
cm

: tanggal ………………………………………………..……

Date of First Registered

date

Diterima di UGM melalui : UMPTN/PBUD/PBAD/………………………………….………....
Accepted in UGM via

Alamat

: ……………………………………………………………………………………………..
……………………………………………………………………………………………..
……………………………………………………………………………………………..
Nomor Telepon/Handphone : .………………………………………………………………………………………...…..
Address

Phone number/Mobile phone

Email email
: ……………………………………………………………………………………………..
Asal Sekolah/Pendidikan sebelumnya, tahun : …………………………………………………………………………...
Previous School of education, year

Nama Orang tua

: …..…………………………….……… Pekerjaan : ……………...……………………..

Name of Parent

Occupation of Parent

Alamat

: ……………………………………………………………………………………………..

Address of Parent

Tugas Akhir tipe

: Skripsi/Tesis

Type of Thesis

Script/Thesis

Judul
Title

Dosen Wali

: ……………………………………………………………………………………………..
……………………………………………………………………………………………..
……………………………………………………………………………………………..
: ……………………………………………………………………………………………..

Academic Advisor

Pembimbing I

: ……………………………………………………………………………………………..

Script/Thesis Advisor

Pembimbing II

: ……………………………………………………………………………………………..

Script/Thesis Co-Advisor

Ujian pendadaran tanggal

: ……………………………………………………………………………………………..

Date of Final Examination

Yudisium

: tanggal …………………………………………………………………………………….

Judicium

date of judicium

Terhitung sejak yudisium, maka:

Umur

As for judicium, then

Age

Lama studi

: ………………….….

tahun, …………..……… Bulan
Year

: ………………….….

Time of Studies

Month

tahun, ….…………….… bulan
Year

Month

Indeks Prestasi Kumulatif : ……………………… Predikat : Memuaskan/Sangat Memuaskan/Cum Laude/ ………
Grade-Point Average
Predicate
: Satisfy/ Very Satisfactory/ Cum Laude ………………………………
Penyelesaian tugas akhir : …………………….... bulan
Script/Thesis completion

Jika pernah cuti, maka

Month

: lama cuti

If ever leave, then

: …….. semester,

duration of leave

Alasan

semester

tahun : ………………………….…..
year

: …………………………………………………………….…...

Reason

Pernah menjadi asisten

:

As assistant to

1. ……………………..…..…………….………....

tahun …………………………………...……………..
year

2. ………………………..…..……………….……

tahun ……………………………………...…………..
year

Jika pernah menerima beasiswa, sebutkan instansi pemberi beasiswa :
For scholarship program, please mention the funding of the scholarship

1.

……………………..…..…………….………....

2.

………………………..…..……………….……

tahun …………………………………...……………..
year

tahun ……………………………………...…………..
year

Jika mahasiswa ikatan dinas, sebutkan instansi yang memberi beasiswa :
For apprenticeship program, please mention the fundinginstitution

……………………………………………………………………………………………………………………….........
Jika mahasiswa tugas belajar, sebutkan instansi asal :
For grantee program, please mention the sending institution

……………………………………………………………………………………………………………………….........
Yogyakarta, …………………………………
Diisi dengan sebenar-benarnya
Filled with truth

( ……………………………... )