A k s e s d i W e b s i t e :

W W W . U N E J . A C . I D

K l i k

K l i k

P E R
A

B .
C

B "l ou kn d u h a n "

F o r m

T I K

U j i a n

E T E N

S u s u

T U

P e n g a j u a n
p e r m o h o n a n
u j i
d i s e r t a i d e n g a n
a l a s a n
y a n
F a k u l t a s / K e t u a
P r o g r a m
S t
A p a b i l a
d i s e t u j u i F a k u l t a s /
b e r i k a n
l e m b a r F 1
F a k u l t a s
M a h a s i s w a
m e n g h u b u n g i
m a t a k u l i a h
d a n
m e n y e r a h
( F 1 ) u n t u k
d i t a n d a t a n g a n i
o p e r a t o r P r o g r a m
S t u d i / J u r
p e r s e t u j u a n
K e t u a
J u r u s a n
M a h a s i s w a
m e n y e r a h k a n
t e l a h
d i t a n d a t a n g a n i K e t u a
F a k u l t a s / P r o g r a m S t u d i u n t
p e r s e t u j u a n
D e k a n

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KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

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UNIVERSITAS JEMBER
Jl. Kalimantan 37 Kampus Tegal Boto Kotak Pos 159
Telp. (0331)-330224, 336579, 336580, 333147, 334267, 339029 Fax (0331)-339029
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mengajukan permohonan mengikuti ujian susulan :

Matakuliah

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Nama Dosen

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Hari/Tanggal Ujian

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

Pemohon,

......................

Diketahui, tanggal ...........................

Ketua Jurusan,
Nilai Ujian : ................. (.........)
Tanggal

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

Menyetujui,tanggal .........................
Dosen Pengampu,

(.................................................)
NIP

(.....................................................)
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UNIVERSITAS JEMBER
Jl. Kalimantan 37 Kampus Tegal Boto Kotak Pos 159
Telp. (0331)-330224, 336579, 336580, 333147, 334267, 339029 Fax (0331)-339029
Jember (68121)

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Lembar Mahasiswa

PERMOHONAN PANGAJUAN UJIAN SUSULAN

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Alasan

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

mengajukan permohonan mengikuti ujian susulan :

Matakuliah

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

Nama Dosen

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

Hari/Tanggal Ujian

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

Ruangan

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

Pemohon,

......................

Nilai Ujian : ................. (.........)

Tanggal

Diketahui, tanggal ...........................

Ketua Jurusan,

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

Menyetujui,tanggal .........................
Dosen Pengampu,

(.................................................)
NIP

(.....................................................)
NIP.
Diketahui, tanggal ......................
Dekan/Pembantu Dekan I,

(.................................................)
NIP.