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POLITEKNIK KP SIDOARJO Nomor :

Jl. Raya Buncitan Kotak Pos 1 Sedati – SidoarjoJawaTimur. 61253 2 2 2


Tanggal Efektif : 2 Agustus 2018
Revisi ke : -
FORMULIR
USULAN JUDUL PKL

Nama Taruna : ………………………………………………………………………………………………………..

NIT : ………………………………………………………………………………………………………..

Dosen Pambimbing : 1. ..........................................................................................................................................


2. ..........................................................................................................................................
Judul PKL yang akan : ………………………………………………………………………………………………………..
diambil
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..

Lokasi PKL : ………………………………………………………………………………………………………..


………………………………………………………………………………………………………..

Sidoarjo, ……………………………….............
Menyetujui,
Dosen Pembimbing1, Dosen Pembimbing 2,

______________________________ ____________________________
NIP. NIT.

Mengetahui,
Ketua Program Studi ………..

…………………………………..
NIP. ……………………………

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