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FORMULIR PENDAFTARAN PCB DESIGN COMPETITION *

*harap di isi dengan huruf Cetak


PESERTA
Nama Lengkap : ________________ Tempat/tgl Lahir :________________
NIM

: ___________________No.KTP/SIM :________________

Fakultas

: __________________ Program Studi :________________

Universitas

: _________________________________________________

Alamat

: ___________________________________________________

Telp/Hp

: ___________________Email :_________________

CP : Septian Adi Chandra : (0857 5848 6967)


M.Sutanto Gumay : (0852 7341 6502)

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