Form Daftar Wisuda S3

PROGRAM PASCASARJANA
UNIVERSITAS TRISAKTI
_________________________________________________________________________________FORM
_____

0008____

PENDAFTARAN WISUDA

PROGRAM STUDI : Doktor Ilmu Ekonomi Konsentrasi Ekonomi dan Keuangan Syariah

1.

Nama

:_______ ________________________________(lengkap dg gelar S1dan S2)

2.

NIM/NIRM

: __________________________________________________________

3.

Alamat

: ________ _______________________________________________________
: _________________________________________________________

4.

Telepon Rumah

: _____________________

Telp. Kantor : ______________________

5.

Tempat & Tanggal Lahir

: __________________________________________________________

6.

Agama

: __________________________________________________________

7 . Jenis Kelamin

: __________________________________________________________

8 . Konsentrasi

: ___________________________________________________________

9.

: __________________________

Nama Ayah

Nama Ibu:_____________________

10. Judul Disertasi (B. Indonesia):____________________________________________________________
____________________________________________________________
11. Judul Disertasi (Bhs.Inggris) :__________________________________________________________
_________________________________________________________________

12. Ukuran Toga

: __________________________________________________________

Jakarta,

20…

Mahasiswa yang bersangkutan,

( _____________________________ )

Catatan : Lampirkan Pasphoto terbaru (berlatar belakang warna Biru) ukuran 3 x 4 sebanyak 10 Lembar.