FORMULIR PENGAJUAN KERJA PRAKTEK

KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS JENDERAL SOEDIRMAN
FAKULTAS PERIKANAN DAN ILMU KELAUTAN
Jalan dr. Suparno Komp. GOR Susilo Sudarman Karangwangkal Purwokerto
Telp. & Fax. (0281) 642360 & 7607433 Website : fpik.unsoed.ac.id

FORMULIR PENGAJUAN KERJA PRAKTEK (Ijon/Biasa)
Nama mahasiswa
NIM
Program Studi
Judul

:
:
:
:

Permasalahan
(Jika tidak cukup bisa ditulis
dilembar terpisah)

:

1.

Pembimbing Akademik
Prasarat
:
IPK
:
Jumlah Nilai E
:
Komentar
:

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

........................................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................
…………………… SKS
……………………
……………………
……………………

KARTU SEMINAR
DISETUJUI
TIDAK DISETUJUI

Purwokerto,……………………….20…….
Pembimbing Akademik,
(…………………………………..)
2.

Sekretariat Komisi
Persyaratan Administrasi

Sudah Lengkap

Belum Lengkap
Purwokerto,……………………….20…….
Petugas Komisi,

3.

4.

(…………………………………..)
Riwayat Konsultasi (Jika Ada)
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Nama Dosen
Tanda Tangan
1. ………………………………………………….
1. ………………………………………………….
2. ………………………………………………….

2. ………………………………………………….
3. ………………………………………………….
3. ………………………………………………….
4. ………………………………………………….
4. ………………………………………………….
Ketua Program Studi
Kesesuaian topik penelitian dengan program Studi
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Usulan Calon Pembimbing :
…………………………………………………………….
Purwokerto,……………………….20…….
Kaprodi,
(…………………………………..)

5.

Tim Komisi Tugas Akhir
Pembimbing

:

Catatan

:

………………………………………………………………………

1.

…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
Dr. Rer.nat. Hamdan Syakuri, M.Si
:
Purwokerto,……………………….20…….

2.

Ir. H. Arif Mahdiana, M.Si.

:

3.

Dr. F. Eko Dwi Haryono, S.Pi., M.Si.

:

Ketua Komisi Tugas Akhir,
Dr. Ir. P. Hary Tjahja S., MS
NIP. 19590912 198511 1 001

Mahasiswa melampirkan :
- Daftar nilai/Transkip sementara
- FC KSM terakhir yang mencantumkan KP