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KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS LAMPUNGBADAN PELAKSANA KKN UNIVERSITAS LAMPUNG
Jl. Sumantri Brojonegoro No. 1 Gedung Meneng Bandar LampungTelp. (0721) 70424! "a# (0721) 70424
FORMULIR PENDAFTARAN MAHASISWA KKN TAHUN 2016
A. DATA PERIBADI
1. Nama $
%%%%%%%%%%%%%%%%%%%%%%%%%.2. N&M $
%%%%%%%%%%%%%%%%%%%%%%%%%.'. &rogram Studi $
%%%%%%%%%%%%%%%%%%%%%%%%%.4. aulta* $
%%%%%%%%%%%%%%%%%%%%%%%%%.
+. ,on*entra*i $
%%%%%%%%%%%%%%%%%%%%%%%%%.. Total S,S-&,/ $
%%%%%%%%%%%%%%%%%%%%%%%%%.7. Tempat Tanggal Lair $
%%%%%%%%%%%%%%%%%%%%%%%%%.. lamat 3omi*ili $
%%%%%%%%%%%%%%%%%%%%%%%%%.. Jeni* ,elamin $
%%%%%%%%%%%%%%%%%%%%%%%%%.10. 5o66 $
%%%%%%%%%%%%%%%%%%%%%%%%%.11. ,ealian ,u*u* $
%%%%%%%%%%%%%%%%%%%%%%%%%.12. Telpon 8uma $
%%%%%%%%%%%%%%%%%%%%%%%%%.1'. 5& $
%%%%%%%%%%%%%%%%%%%%%%%%%.14. Tempat tinggal *al $
%%%%%%%%%%%%%%%%%%%%%%%%%.1+. 9uran Baju $
%%%%%%%%%%%%%%%%%%%%%%%%%.B. DATA ORANG TUA
1. aa. Nama $
%%%%%%%%%%%%%%%%%%%%%%%%%.6. &eerjaan $
%%%%%%%%%%%%%%%%%%%%%%%%%.:. Telpon 8uma $
%%%%%%%%%%%%%%%%%%%%%%%%%.
d. 5p $
%%%%%%%%%%%%%%%%%%%%%%%%%.2. lamat ;rang Tua $
%%%%%%%%%%%%%%%%%%%%%%%%%.C. DATA ORANG YANG SEGERA DAPAT DIHUBUNGI
1. Nama $
%%%%%%%%%%%%%%%%%%%%%%%%%.2. lamat $
%%%%%%%%%%%%%%%%%%%%%%%%%.'. Telp-5& $
%%%%%%%%%%%%%%%%%%%%%%%%%.4. 5u6ungan Maa*i*
7/23/2019 Formulir_Pendaftaran_KKN.doc
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3emiian data ini *aa 6uat dengan *e6enarna untu dipergunaan *e6agai*arat penda"taran :alon pe*erta ,,N Taun 201. pa6ila ada data ang *aa6uat ternata pal*u! maa *aa 6er*edia menerima *an*i *e6agimaname*tina.
Mengetaui! Bandar Lampung!201
&em6im6ing ademi =ang Mem6uat.........................
(..............................................)(................................................)N& $........................................N&M $.......................................
,etua Juru*an..................
(................................................)N& $........................................