FM-BINUS-AA-FPU-117/V2R0

FORMULIR PERMOHONAN AKTIF KEMBALI

RE-ACTIVE APPLICATION FORM

Nama
: …………………………………………………………………………...
Name
NIM
: …………………………………………………………………………...
Student ID
Fakultas/Sekolah
: …………………………………………………………………………...
Faculty/School
Program Studi
: …………………………………………………………………………...
Study Program

Program : …………………………………………………………………………...

Jenjang Studi
: …………………………………………………………………………...
Education Level
Alamat
: …………………………………………………………………………...
Address
Telepon  Rumah
: …………………………………………………………………………...
Phone Number Home
 Kantor
: …………………………………………………………………………...
Office
 HP
: …………………………………………………………………………...
Mobile Phone

 E-mail : …………………………………………………………………………...

Alasan tidak aktif

: ………………………………………………………………………………………...
The reason being inactive

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Tahun Akademik
Semester akan aktif kembali : ………………………………… ………... / ................
Academic Year
Period of re-active

Jakarta,

Hormat saya, Mengetahui,

Sincerely Yours, Acknowledged by,

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Mahasiswa Orang Tua / Wali Mahasiswa
Student Parent / Student Guardian
 FM-BINUS-AA-FPU-117/V2R0

Diisi oleh Konselor

Filled by counselor

Aktif Terakhir Tanda tangan Konselor

: …………………………………………………….. Signature by counselor
Last Active
Sisa Masa Studi
: ……………………………………………………..
Study Period Left
Batas Masa Studi
: ……………………………………………………..
Limit of Study Period
Jumlah Cuti
: ……………………………………………………..
Number of Official Leave Diperiksa oleh*,
IPK Terakhir Checked by
: ……………………………………………………..
Last GPA
SKS Kumulatif
: ……………………………………………………..
Cumulative SCU
Status Peminjaman Buku
: ……………………………………………………..
Book Lending Status
Catatan
: …………………………………………………………………………….
Note

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Downgrade : Ya / Yes Tidak / No

Perjanjian : Ya / Yes Tidak / No

Agreement
*Min. Binusian Grade 10 dari unit yg berwenang / Min. Binusian Grade 10 from the authorized unit

Menyetujui / Menolak
Approve / Reject

Dekan / Kepala Sekolah ………………………

Dean / Head of School ………………………

Rincian pembayaran diisi oleh Student Services Center

Payment detail is filled by Student Services Center

Jenis Nilai Cara Pembayaran Tanda Tangan Petugas

Type Score Payment Method Signature by Staff

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Diperiksa oleh*,
Checked by
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*Min. Binusian Grade 10 dari unit yg berwenang / Min. Binusian Grade 10 from the authorized unit