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PERTAMINA
SERIKAT PEKERJA PERTAMINA PATRA WIJAYAKUSUMA
HUT PERTAMINA KE – 59PT. PERTAMINA (PERSERO) RU IV CILACAP SPP.PWKSPP.PWKFSPPB
FORMULIR PENDAFTARAN LKTI
Nama Tim : ..................................................................................................................Nama Instansi : ..................................................................................................................Jumlah Anggota : ..................................................................................................................Alamat Instansi : .................................................................................................................. ..................................................................................................................
Telepon : .................................................................................................................. E-mail : ..................................................................................................................
Judul Karya Tulis : .................................................................................................................. .................................................................................................................. ..................................................................................................................
Lomba yang di ikuti : Lomba Karya Tulis Ilmiah (LKTI) HUT Pertamina ke-59
*) Telepon dan e-mail adalah kontak yang dapat dihubungi panitia kepada tim/peserta lomba
DATA PESERT A
1. KetuaNama Lengkap : ......................................................................................... Nomor Induk Mahasiswa : ......................................................................................... Jurusan/Fakultas/Angkatan : .........................................................................................Alamat Rumah : .........................................................................................
.........................................................................................Telepon/HP : .........................................................................................Email : .........................................................................................
2. Anggota 1Nama Lengkap : ......................................................................................... Nomor Induk Mahasiswa : ......................................................................................... Jurusan/Fakultas/Angkatan : .........................................................................................Alamat Rumah : .........................................................................................
.........................................................................................Telepon/HP : .........................................................................................
PANITIA GEBYAR HUT PERTAMINA 59Sekretariat : Kantor SPP.PWK, Komplek Gedung PatraGraha Telp : (0282) 509898 Fax : (0282)509897 1Jalan MT. HaryonoLomanisCilacapCp : Sunaryo Adi Putra – 0815 9574 413 Onward Andika – 0813 9111 5046
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PERTAMINA
SERIKAT PEKERJA PERTAMINA PATRA WIJAYAKUSUMA
HUT PERTAMINA KE – 59PT. PERTAMINA (PERSERO) RU IV CILACAP SPP.PWKSPP.PWKFSPPB
Email : .........................................................................................3. Anggota 2
Nama Lengkap : ......................................................................................... Nomor Induk Mahasiswa : ......................................................................................... Jurusan/Fakultas/Angkatan : .........................................................................................Alamat Rumah : .........................................................................................
.........................................................................................Telepon/HP : .........................................................................................Email : .........................................................................................
Dengan ini saya menyatakan keikutsertaan diri/tim kami pada acara “Part Of Society” HUT Pertamina yang ke-59 dalam Lomba Karya Tulis Ilmiah (LKTI), serta akan mengikuti prosedur kompetisi yang ada.
.................,.................................2016Tanda Tangan,
...............................................................
(Nama Lengkap Ketua Tim)
Bersama ini kami lampirkan :
1. Fotocopy kartu tanda mahasiswa/pengenal yang berlaku
*)Formulir ini boleh diperbanyak/dicopy
PANITIA GEBYAR HUT PERTAMINA 59Sekretariat : Kantor SPP.PWK, Komplek Gedung PatraGraha Telp : (0282) 509898 Fax : (0282)509897 2Jalan MT. HaryonoLomanisCilacapCp : Sunaryo Adi Putra – 0815 9574 413 Onward Andika – 0813 9111 5046
Foto3x4
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