Formulir Pendaftaran LKTI PIGORA Season II Unesa

FORMULIR PENDAFTARAN

LOMBA KARYA TULIS ILMIAH TINGKAT NASIONAL

UNIVERSITAS NEGERI SURABAYA

FAKULTAS ILMU SOSIAL

BADAN EKSEKUTIF MAHASISWA JURUSAN GEOGRAFI

1. Judul LKTI : ……………………………………………………..

……………………………………………………....

2. Biodata Peserta

1. Nama lengkap : ..................................................................................

Tempat/tanggal lahir : ..................................................................................

Alamat tempat tinggal : ..................................................................................

No.telp/HP : ..................................................................................

Alamat e-mail : ..................................................................................

2.Nama lengkap : ..................................................................................

Tempat/tanggal lahir : ..................................................................................

Alamat tempat tinggal : ..................................................................................

No.telp/HP : ..................................................................................

Alamat e-mail : ..................................................................................

3.Nama lengkap : ..................................................................................

Tempat/tanggal lahir : ..................................................................................

Alamat tempat tinggal : ..................................................................................

No.telp/HP : ..................................................................................

Alamat e-mail : ..................................................................................

3. Sekolah Asal

Asal Sekolah : ........................................................................................

Alamat Sekolah : ........................................................................................

Kode Pos : ........................................................................................

No.telp : ........................................................................................

4. Prestasi yang Pernah Diraih Selama SMA

1. .............................................................................................................................

2. .............................................................................................................................

3. .............................................................................................................................

5. Pernyataan

Dengan ini saya menyatakan bahwa data yang diisikan dalam formulir ini adalah benar.

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yang membuat pernyataan,

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