00-form_pendaftaranujianpkl.docx

KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGIUNIVERSITAS BRAWIJAYA

PROGRAM KEDOKTERAN HEWANJalan Mayjen Haryono No : 169 Malang 65145

Telp. +62341- 573642, Fax. +62341- 573642, 551611 psw 362http://www.pkh.ub.ac.id email : pkh_ub@ub.ac.id

Form Pendaftaran Ujian PKL

NIM : ..............................................................

Nama MHS : ..............................................................

Judul : ............................................................................................................

..........................................................................................................................................

..........................................................................................................................................

Instansi PKL : ...........................................................................................................

Yang Akan Diselengggarakan Pada :

Hari : ………………………………………..

Tanggal : ………………………………………..

Pukul : ………………………………………..

Tempat Ujian : ………………………………………..

Nama Tim PengujiTanda

Tangan

Pembimbing 1 :

NIP.

Pembimbing 2 :

NIP.

Penguji :

NIP.

Mengetahui Malang, .....................................Wakil Bidang Akademik

Prof.Dr.Aulanni'am,drh.,DES NIP. 19600903 198802 2 001