Surat Perizinan Orangtua

8/16/2019 Surat Perizinan Orangtua

1/8

BADAN EKSEKUTIF MAHASISWA KELUARGA MAHASISWA

FAKULTAS KEDOKTERAN

UNIVERSITAS SWADAYA GUNUNG JATI

SEKRETARIAT : KAMPUS 3 GEDUNG FAKULTAS KEDOKTERAN

Jl. TerusanPemuda No.A !"re#on $%3&

Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3

!"re#on, Aus/us &(3

Nomor : ))0LKMM01EM)FKUGJ02II0&(3

Lampiran : 1 !r"a#

Ha$ : %!rmo&onan i'in

Ke'ada /4.

Oran( T)a * Wa$i Ma&a#i#+a An("a,an -.11 /an -.1-

D" Tem'a/

Denan 5orma/,

Se4u#unan a6an d"la6sana6ann7a a8ara LKMM 0La,i&an K!p!mimpinan /an

Mana!m!n Ma&a#i#+a2 -n/

G!n!ra,ion -.13 ole4 Ba/an E"#!"),i4 Ma&a#i#+a FK Un+a(a,i5 6am" sela6u 'an"/"a mena9u6an 'ermo4onan ""n un/u6 'u/ra0" dar" 1a'a60I#u un/u6

men"6u/" LKMM 7an "ns7a Alla4 a6an d"la6sana6an 'ada :

5ar" : Juma/ ) M"nu

Tanal : + ) & Jul" &(3

Tem'a/: ;#elum d"/en/u6an<

Se4u#unan denan a6an d"ada6ann7a a8ara /erse#u/ ma6a 6am" menanar6an #"a7a

se#esar Rp617.6...58 p!r ma&a#i#+a*i. Dem"6"anla4 sura/ 'ermo4onan ""n "n" 6am" sam'a"6an.

A/as 'er4a/"an dan 6e4ad"rann7a 6am" u8a'6an /er"ma 6as"4.

5orma/ Kam"

Ke/ua Pela6sana Se6re/ar"s

In#an Ri'"i$$a& Yo9i!na K)#)ma D!+i


2/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3

NIM. &((+=3(3= NIM. &((=3(%

Mene/a4u"

Ke/ua 5MPD

N)(ra&a A"ar a!#ar

2009730102

!"re#on, & Aus/us &(3


3/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3

Nomor : (&0LKMM0FK)UNS>AGATI0&(3

Lam'"ran : )

5al : % !minaman Baran(

Ke'ada an Ter4orma/,

Ka)r Sarana %ra#arana FK

Un#+a(a,i

d" )

Tem'a/

D

enan 5orma/,

Seala 'u9" 4an7a #a" Alla4 S>T, Tu4an semes/a alam 7an /ela4 mem#er"6an n"6ma/

se4a/ 9asman" dan ro4an" 6e'ada 6"/a.

Se4u#unan a6an d"ada6an a8ara ?La,i&an K!p!mimpinan Mana!m!n Ma&a#i#+a

Fa")$,a# K!/o",!ran Un#+a(a,i -.13?, 6am" 'an"/"a LKMM Fa6ul/as Kedo6/eran Uns@aa/"

#erma6sud un/u6 M!minam 1 B)a& %ro;!",or /an So)/#;#,!m 7an Ins7a Alla4 a6an

d"una6an 'ada :

5ar" : Sa#/u ) M"nu

Tanal : = * Aus/us &(3

Tem'a/: Aud"/or"um FK Uns@aa/"

Dem" 6elan8aran /erselenaran7a 6e"a/an "n", 6am" mo4on 'ar/"s"'as" dan 6on/r"#us"

'ada a8ara 7an 6am" ma6sud d" a/as.

Dem"6"an sura/ 'em"n9aman "n" 6am" sam'a"6an, a/as 'er4a/"an dan 6er9asaman7a 6am"

u8a'6an /er"ma6as"4.

5orma/ 6am",

Ke/ua 1EM FK Ke/ua Pela6sana

Ario A()n( W M6 Ha#i Tria,i

NPM. 110170005 NPM. 110170040

Mene/a4u",

>a6"l De6an III FK Uns@aa/"

/r6 H6 Ria6"l De6an III FK Uns@aa/"

&. Kaur Kema4as"s@aan FK Uns@aa/"



4/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3

Nomor : (0LKMM0FK)UNS>AGATI0&(&

Lam'"ran : Lem#ar

5al : %! rmo&onan I'in


Oran( ,)a*Wa$i Ma&a#i#+a*i

FK An("a,an -.11 /an -.1-

d" )

Tem'a/

Denan 4orma/,



Kam", 'an"/"a ?La,i&an K!p!mimpinan Mana!m!n Ma&a#i#+a 0LKMM2 Fa")$,a#

K!/o",!ran Un#+a(a,i -.13?, memo4on ""n 6e'ada oran /ua a/au @al" dar" ma4as"s@a0"

#a4@asann7a a6an d"ada6an a8ara B LKMM? 7an a6an d"la6sana6an 'ada:

5ar" : Sa#/u ) M"nuTanal : = * Aus/us &(3

Tem'a/: Kam'us Fa6ul/as Kedo6/eran Uns@aa/"

1"a7a : R'. *(.(((0 oran

A8ara "n" #er/u9uan un/u6 ma4as"s@a 7an mem'un7a" 9"@a 6e'em"m'"nan, s"6a'

6e/eladanan, #er'"6"r 6r"/"s, #"9a6 dalam menam#"l 6e'u/usan, ser/a solu/"C dalam 'en7elesa"an

masala4. Dem"6"an sura/ 'em#er"/a4uan "n" 6am" sam'a"6an. A/as 'er4a/"an dan 'ar/"s"'as"n7a,

6am" u8a'6an /er"ma 6as"4.

5orma/ 6am",

Ke/ua 1EM FK Ke/ua Pela6sana

Ario A()n( W6 M6 Ha#i Tria,i

NPM. 109170015 NPM. 110170040

Mene/a4u",

>a6"l De6an III FK Uns@aa/"

/r6 Ri


5/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3

Nomor : (30LKMM0FK)UNS>AGATI0&(3

Lam'"ran : ;sa/u< #endel 'ro'osal

5al : %!m!ri,a&)an K!(ia,an


D!"an Fa")$,a# K!/o",!ran

Un#+a(a,i

d" )

Tem

'a/

Denan 4orma/,




K!/o",!ran Un#+a(a,i -.13?, mem#er"/a4u6an #a4@asann7a a6an d"ada6an a8ara BLKMM?

7an a6an d"la6sana6an 'ada:

5ar" : Sa#/u ) M"nu


Tem'a/: Kam'us FK Uns@aa/"





5orma/ 6am",


M6 Ha#i Tria ,i Uni=)! Har/i;an,i %6

NPM. 110170040 NPM. 110170070


6/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3


Nomor : ($0LKMM0FK)UNS>AGATI0&(3

Lam'"ran : )



Wa"i$ D!"an I Fa")$,a#

K!/o",!ran Un#+a(a,i

d" )

Tem'a/

Denan 4orma/,




K!/o",!ran Un#+a(a,i -.13?, mem#er"/a4u6an #a4@asann7a a6an d"ada6an a8ara B LKMM?


5ar" : Sa#/u ) M"nu







5orma/ 6am",


M6 Ha#i Tria,i Uni=)! Har/i;an,i %6

NPM. 110170040 NPM. 110170070


7/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3


Nomor : (%0LKMM0FK)UNS>AGATI0&(3

Lam'"ran : )



Wa"i$ D!"an II Fa")$,a#


d" )

Tem'a/

Denan 4orma/,






5ar" : Sa#/u ) M"nu







5orma/ 6am",



NPM. 110170040 NPM. 110170070


8/8


FAKULTAS KEDOKTERAN




Tele'on : (&3)$*3+&*, Fa- : (&3)$**+&3


Nomor : (0LKMM0FK)UNS>AGATI0&(3

Lam'"ran : )



Wa"i$ D!"an III Fa")$,a#


d" )

Tem'a/

Denan 4orma/,






5ar" : Sa#/u ) M"nu







5orma/ 6am",



NPM. 110170040 NPM. 110170070

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Surat Perizinan Orangtua