UNIVERSITAS GADJAH MADA - FAKULTAS TEKNIK
UNIVERSITAS GADJAH MADA – FACULTY OF ENGINEERING
JURUSAN 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
FORMULIR PERMOHONAN
PERPANJANGAN SURAT KEPUTUSAN (SK) DOSEN PEMBIMBING
(Application Form for Extension of Letter of Decree of Script /Thesis Advisor)
Berlaku maksimum 1 (satu) semester saja Valid for maximum of 1 (one) semester
Nama Mahasiswa : ______________________________________________
(Name)
NIM : ____________________________________
(Student No.)
Angkatan : ___________
(Academic Year)
Topik Penelitian : ______________________________________________________________
(Research Topic) ______________________________________________________________ ______________________________________________________________
Judul Sementara : ______________________________________________________________
(Tentative Title) ______________________________________________________________ ______________________________________________________________
______________________________________________________________
Pembimbing Utama : ____________________________________
(Advisor)
Pembimbing Pendamping : ____________________________________
(Co-Advisor)
Syarat-Syarat (Check-List) : 1. Salinan Formulir Kesediaan Dosen Pembimbing
(Copy of Advisor Proposal Form) …..
2. Draft yang sudah disetujui oleh pembimbing dan penguji ujian proposal
(Approved draft) …..
3. Fotokopi Surat Keputusan (SK) Dosen Pembimbing lama
(Copy of Previous Letter of Decree of Script/Thesis Advisor) …..
Yogyakarta, _ _ _ _ _ _ _ __ _ _
( _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )
Menyetujui, (Approve)
Pengelola Program Studi Pembimbing Utama
(Program Manager) (Advisor)
