LAMPIRAN FORM ISIAN
UNTUK KONTRAK BANTUAN DANA BERGULIR PROGRAM MAHASISWA WIRAUSAHA UNIVERSITAS NAHDLATUL ULAMA SURABAYA
2017
FORMULIR ISIAN
A. Dat a dan Ident it as:
1. Nama Ket ua Tim :________________________________________________________________ 2. Nomor Pokok Mahasisw a (NPM) :________________________________________________________________ 3. Pr ogr am St udi :________________________________________________________________ 4. Fakult as :________________________________________________________________ 5. No. Handphone :________________________________________________________________ 6. E-mail Ket ua Tim :________________________________________________________________
B. Dat a Bank Pener ima Dana har us r ekening pr ibadi yang ber sangkut an
1. Nama Bank :________________________________________________________________ 2. Alamat Bank :________________________________________________________________ 3. Nama pada Buku Tabungan :________________________________________________________________ 4. Nomor Rekening :________________________________________________________________
Sur abaya,...
Ket ua Tim