FORMULIR PENDAFTARAN
5
civilweekuns YQF3988W civilweek@ft.uns.ac.id civilweek.hms-uns.com Y M QF A 39 K 88 E W A LEGACY, WRITE YOUR HISTORY civilweek@ft.uns.ac.i d 2 0 2 1 ``` FORMULIR PENDAFTARAN NATIONAL PAPER COMPETITION CIVILWEEK 2021 Nama : ........................................................................................................................................ Judul Karya : ........................................................................................................................................ ........................................................................................................................................ Asal Universitas : ........................................................................................................................................ Alamat Universitas : ........................................................................................................................................ ........................................................................................................................................ No. Telepon/Fax : ........................................................................................................................................ E-mail : ........................................................................................................................................ DATA PESERTA Mahasiswa 1 a. Nama : ...................................................................................... b. Tempat, Tanggal Lahir : ...................................................................................... c. Jenis Kelamin : ...................................................................................... d. Jurusan : ...................................................................................... e. Nomor Induk Mahasiswa : ...................................................................................... f. No. Telepon/HP : ...................................................................................... g. E-mail : ...................................................................................... Foto 3x4
Transcript of FORMULIR PENDAFTARAN
civilweekuns
YQF3988W
civilweek.hms-uns.com
YMQFA39K88EWA LEGACY, WRITE YOUR HISTORY [email protected]
2 0 2 1
```
FORMULIR PENDAFTARAN NATIONAL PAPER COMPETITION
CIVILWEEK 2021
Nama : ........................................................................................................................................
Judul Karya : ........................................................................................................................................
........................................................................................................................................
Asal Universitas : ........................................................................................................................................
Alamat Universitas : ........................................................................................................................................
........................................................................................................................................
No. Telepon/Fax : ........................................................................................................................................
E-mail : ........................................................................................................................................
DATA PESERTA
Mahasiswa 1
a. Nama : ......................................................................................
b. Tempat, Tanggal Lahir : ......................................................................................
c. Jenis Kelamin : ......................................................................................
d. Jurusan : ......................................................................................
e. Nomor Induk Mahasiswa : ......................................................................................
f. No. Telepon/HP : ......................................................................................
g. E-mail : ......................................................................................
Foto
3x4
civilweekuns
YQF3988W
civilweek.hms-uns.com
YMQFA39K88EWA LEGACY, WRITE YOUR HISTORY [email protected]
2 0 2 1
```
FORMULIR PENDAFTARAN NATIONAL PAPER COMPETITION
CIVILWEEK 2021
Mahasiswa 2
a. Nama : ...........................................................................................
b. Tempat, Tanggal Lahir : ...........................................................................................
c. Jenis Kelamin : ...........................................................................................
d. Jurusan : ...........................................................................................
e. Nomor Induk Mahasiswa : ...........................................................................................
f. No. Telepon/HP : ...........................................................................................
g. E-mail : ...........................................................................................
Mahasiswa 3
a. Nama : ...........................................................................................
b. Tempat, Tanggal Lahir : ...........................................................................................
c. Jenis Kelamin : ...........................................................................................
d. Jurusan : ...........................................................................................
e. Nomor Induk Mahasiswa : ...........................................................................................
f. No. Telepon/HP : ...........................................................................................
g. E-mail : ...........................................................................................
Dosen Pembimbing
a. Nama : ...........................................................................................
b. Tempat, Tanggal Lahir : ...........................................................................................
c. Jenis Kelamin : ...........................................................................................
d. NIP : ...........................................................................................
e. Bidang Keahlian : ...........................................................................................
f. No. Telepon/HP : ...........................................................................................
g. E-mail : ...........................................................................................
Foto
3x4
Foto
3x4
Foto
3x4
2 0 2 1
```
FORMULIR PENDAFTARAN NATIONAL PAPER COMPETITION
CIVILWEEK 2021
PERNYATAAN KEIKUTSERTAAN
Yang bertanda tangan dibawah ini :
a. Nama :......................................................................................................................
b. Tempat, Tanggal Lahir :......................................................................................................................
c. Asal Universitas :......................................................................................................................
d. Alamat Universitas :......................................................................................................................
:......................................................................................................................
e. Kode Pos Universitas :......................................................................................................................
f. Nomor Induk Mahasiswa :......................................................................................................................
g. Jurusan/Prodi :......................................................................................................................
h. Alamat Mahasiswa :......................................................................................................................
:......................................................................................................................
i. No. Telepon/HP :......................................................................................................................
Mewakili tim saya yang beranggotakan
Dosen Pembimbing :......................................................................................................................
Mahasiswa :(1) .................................................................................................................
(2) .................................................................................................................
(3) .................................................................................................................
Dengan ini, saya menyatakan telah mendaftarkan diri sebagai peserta National Paper Competition CIVILWEEK
UNS 2021 dan bersedia mengikuti semua peraturan yang telah diterapkan.
…………………, ……. ………………………….. 2021
Menyetujui,
Ketua Jurusan/Bidang Kemahasiswaan Ketua Tim
( ) ( )
2 0 2 1
civilweekuns
YQF3988W
civilweek.hms-uns.com
MQFA39K88EWA LEGACY, WRITE YOUR HISTORY [email protected] civilweek.hms-uns.com
```
Yang bertanda tangan di bawah ini :
1. Nama : ....................................................................................................................................
NIM : ....................................................................................................................................
Jabatan : ....................................................................................................................................
2. Nama : ....................................................................................................................................
NIM : ....................................................................................................................................
Jabatan : ....................................................................................................................................
3. Nama : ....................................................................................................................................
NIM : ....................................................................................................................................
Jabatan : ....................................................................................................................................
Judul Karya Tulis ............................................................................................................................. :
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
………………………
Menyatakan bahwa karya tersebut asli buatan sendiri, bukan jiplakan dan belum pernah menjuarai lomba
sejinis sebelumnya.
Pernyataan ini kami buat dengan sebenar-benarnya. Apabila dikemudian hari terbukti tidak benar, saya
bersedia menerima sanksi yang ditetapkan oleh pihak panitia LOMBA NATIONAL PAPER COMPETITION
2021.
…………………, ……. ………………………….. 2021
Ketua Kelompok,
( )
Materai 10000
2 0 2 1
```
LEMBAR PENGESAHAN NATIONAL PAPER COMPETITION
CIVILWEEK 2021
1. Nama Tim :......................................................................................................................
2. Judul Karya :......................................................................................................................
3. Ketua Tim :......................................................................................................................
a. Nama Lengkap :......................................................................................................................
b. NIM :......................................................................................................................
c. Jurusan/Fakultas :......................................................................................................................
d. Universitas :......................................................................................................................
e. Alamat Rumah :......................................................................................................................
f. E-mail :......................................................................................................................
g. No. HP :......................................................................................................................
4. Nama Anggota :(1) .................................................................................................................
(2) .................................................................................................................
5. Dosen Pembimbing
a. Nama Lengkap dan Gelar : .......................................................................................................
b. NIP : .......................................................................................................
…………………, ……. ………………………….. 2021
Dosen Pembimbing Ketua Tim
………………………………………….. …………………………………………..
NIP. NIM.
