FM-BINUS-AA-FPU-754/R1

FORMULIR PERMOHONAN AKTIF KEMBALI

RE-ACTIVE APPLICATION FORM

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

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Mahasiswa
Student
 FM-BINUS-AA-FPU-754/R1

Diisi oleh Staf Layanan Mahasiswa

Filled by Student Services Staff

Aktif Terakhir Paraf Staf Layanan

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

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Perjanjian: Ya/ Yes Tidak/ No

Agreement

Diisi oleh Staf Nilai

Filled by Grading Staff
KD MTK Nama Matakuliah Minimum Nilai UPM Nilai Paraf Staf Nilai
Course Code Course Name Grade Minimum Grade Signature by Grading Staff

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Diperiksa oleh*
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*Min. Binusian Grade 10 dari unit yg berwenang/ Min. Binusian Grade 10 from the authorized unit
 FM-BINUS-AA-FPU-754/R1

Rincian pembayaran diisi oleh Staf Administrasi Keuangan

Payment detail is filled by Financial Administration Staff
Jenis Rincian Biaya Cara Pembayaran Paraf
Item Cost Detail Payment Method Staf Admin Keuangan
Signature by Financial & Admin
Staff

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

Diisi oleh Staf Penjadwalan

Filled by Scheduling staff
Catatan: Paraf
Note Staf Penjadwalan
Signature by Scheduling Staff

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Diperiksa oleh*
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*Min. Binusian Grade 10 dari unit yg berwenang/ Min. Binusian Grade 10 from the authorized unit
 FM-BINUS-AA-FPU-754/R1

Diisi oleh Staf Layanan Mahasiswa

Filled by Student Service Staff
Catatan (Informasi ke Mahasiswa) (Telp/ e-mail)* Signature by Student Service
Note (Information to student) (Telp/ e-mail) Staff

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Mengetahui, Menyetujui/ Menolak,

Knowing Approve/ Reject

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Manajer Operasional Dekan/ Kepala Sekolah ………………………….
Operational Manager Dean/ Head of School ……………………………