Form Daftar Wisuda S3

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1. N a m a :_______ ________________________________(lengkap dg gelar S1dan S2)

2. NIM/NIRM : __________________________________________________________

3. Alamat : ________ _______________________________________________________

: _________________________________________________________

4. Telepon Rumah : _____________________ Telp. Kantor : ______________________

5. Tempat & Tanggal Lahir : __________________________________________________________

6. A g a m a : __________________________________________________________

7 . Jenis Kelamin : __________________________________________________________

8 . Konsentrasi : ___________________________________________________________

9. Nama Ayah : __________________________ Nama Ibu:_____________________

10. Judul Disertasi (B. Indonesia):____________________________________________________________

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11. Judul Disertasi (Bhs.Inggris) :__________________________________________________________

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12. Ukuran Toga : __________________________________________________________

Jakarta, 20…

Mahasiswa yang bersangkutan,

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