PROGRAM PASCASARJANA
UNIVERSITAS TRISAKTI
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FORM 0008
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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):____________________________________________________________
____________________________________________________________
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.