FORM PERMOHONAN SURAT PENGANTAR

Yth. Kasubag Akademik dan Kemahasiswaan FIS Universitas Negeri Malang Mohon dapatnya dibuatkan surat pengantar Wakil Dekan I untuk keperluan: (lingkari di depan pilihan yang sesuai)

1. Observasi ..................................... dalam rangka tugas matakuliah .............................. 2. Penelitian Skripsi/Observasi 3. Program Pengalaman Lapangan (PPL) 4. Kuliah Kerja Lapangan (KKL) 5. Praktek Kerja Lapangan (PKL) *) sudah / belum mengikuti pembekalan

Nama : .............................................................NIM.................................... No. HP ……………........ Anggota : 1. ..........................................................NIM............................................................................ 2. ..........................................................NIM............................................................................ 3.. .........................................................NIM............................................................................ 4. ..........................................................NIM............................................................................ 5. ..........................................................NIM............................................................................ 6. ..........................................................NIM............................................................................ Jurusan : *) HKn/ Geografi / Sejarah / PIPS / Sosiologi

Program Studi : *) Ilmu / Pendidikan ...........................................................................

Surat ditujukan kepada : ............................................................................................................

Tempat Kegiatan yang direncanakan : …........................................................................................................

Waktu (tanggal & bulan) : **) .......................................................................................................

Judul karya Ilmiah :..............................................................................................................

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

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Dosen Pembimbing : 1. Nama : ........................................................... Tanda Tangan ................................... 2. Nama : ........................................................... Tanda Tangan .................................. Mengetahui, Malang, ....................... Ketua/ Sekretaris, Mahasiswa Pemohon, Jurusan/ Prodi ........................... ................................................ .................................................. NIP NIM Keterangan: *) Coret yang tidak perlu **) Waktu Penelitian Skripsi Max. 3 bulan, Penelitian Matakuliah Max. 2 Minggu

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