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FORMULIR REGISTRASI ANGGOTA IKATAN SARJANA KOMUNIKASI INDONESIA (ISKI)

NAMA

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TEMPAT/TGL LAHIR : ................................................................................................ ALAMAT : ................................................................................................ : ................................................................................................ NO TELP/ HP FAX/ E-MAIL : ................................................................................................ : ................................................................................................

LULUS TAHUN : ................................................................................................ PERGURUAN TINGGI : SI : Thn ....................... P.TINGGI : ....................................... : S2 : Thn ....................... P.TINGGI : ....................................... : S3 : Thn ....................... P.TINGGI : .......................................

JUDUL SKRIPSI/ THESIS/ DISERTASI 1. ..

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2. ..

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3. ..

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PEKERJAAN ALAMAT KANTOR

: ................................................................................................ : ................................................................................................

TELP/ FAX/ E-MAIL : ................................................................................................ : ................................................................................................ ISKI CABANG/ KOMISARIAT : ................................................................................................

ALAMAT SEKRETARIAT : .............................................................................................. : .............................................................................................. TELP/ FAX/ E-MAIL : .............................................................................................. *ANGGOTA LAMA/ BARU LAMA BARU

*AKTIF SEBAGAI PENGURUS YA, SEBAGAI ................................................... TIDAK

(KOTA)........................................, TGL .................................... 20.....

TANDA TANGAN Foto

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