Formulir Anugerah Tokoh pers mahasiswa se-Riau (Alumni LPM)

NAMA LENGKAP NOMINATOR :___________________________________________________________________

TEMPAT/TANGGAL LAHIR :___________________________________________________________________

ALAMAT :___________________________________________________________________

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NO. HANDPHONE :______________________/_______________________

EMAIL :_______________________________

TWITTER :@_____________________________

NAMA LEMABGA :_____________________________________________

Pekanbaru,

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*Data diisi dengan huruf kapital.*Melampirkan foto 3x4 (warna) 2lembar.*Menyertakan lampiran tulisan biografi calon nominator.

20 Desember 2013, PKM UIR