Jumlah SKS : ...................................................................... Nama : ......................................................................
IPK : ...................................................................... NIM : ......................................................................
Pengambilan Skripsi Ke : ...................................................................... Jurusan : ......................................................................
Judul Skripsi : ...................................................................... Semester / Th Akademik : ......................................................................
...................................................................... Dosen Pembimbing I : ......................................................................
...................................................................... Dosen Pembimbing II : ......................................................................