PERTAMINA

SERIKAT PEKERJA PERTAMINA PATRA WIJAYAKUSUMA

HUT PERTAMINA KE – 59PT. PERTAMINA (PERSERO) RU IV CILACAP SPP.PWKSPP.PWKFSPPB

FORMULIR PENDAFTARAN LKTI

Nama Tim : ..................................................................................................................Nama Instansi : ..................................................................................................................Jumlah Anggota : ..................................................................................................................Alamat Instansi : .................................................................................................................. ..................................................................................................................

Telepon : .................................................................................................................. E-mail : ..................................................................................................................

Judul Karya Tulis : .................................................................................................................. .................................................................................................................. ..................................................................................................................

Lomba yang di ikuti : Lomba Karya Tulis Ilmiah (LKTI) HUT Pertamina ke-59

*) Telepon dan e-mail adalah kontak yang dapat dihubungi panitia kepada tim/peserta lomba

DATA PESERT A

1. KetuaNama Lengkap : ......................................................................................... Nomor Induk Mahasiswa : ......................................................................................... Jurusan/Fakultas/Angkatan : .........................................................................................Alamat Rumah : .........................................................................................

.........................................................................................Telepon/HP : .........................................................................................Email : .........................................................................................

2. Anggota 1Nama Lengkap : ......................................................................................... Nomor Induk Mahasiswa : ......................................................................................... Jurusan/Fakultas/Angkatan : .........................................................................................Alamat Rumah : .........................................................................................

.........................................................................................Telepon/HP : .........................................................................................

PANITIA GEBYAR HUT PERTAMINA 59Sekretariat : Kantor SPP.PWK, Komplek Gedung PatraGraha Telp : (0282) 509898 Fax : (0282)509897 1Jalan MT. HaryonoLomanisCilacapCp : Sunaryo Adi Putra – 0815 9574 413 Onward Andika – 0813 9111 5046

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PERTAMINA

SERIKAT PEKERJA PERTAMINA PATRA WIJAYAKUSUMA

HUT PERTAMINA KE – 59PT. PERTAMINA (PERSERO) RU IV CILACAP SPP.PWKSPP.PWKFSPPB

Email : .........................................................................................3. Anggota 2

Nama Lengkap : ......................................................................................... Nomor Induk Mahasiswa : ......................................................................................... Jurusan/Fakultas/Angkatan : .........................................................................................Alamat Rumah : .........................................................................................

.........................................................................................Telepon/HP : .........................................................................................Email : .........................................................................................

Dengan ini saya menyatakan keikutsertaan diri/tim kami pada acara “Part Of Society” HUT Pertamina yang ke-59 dalam Lomba Karya Tulis Ilmiah (LKTI), serta akan mengikuti prosedur kompetisi yang ada.

.................,.................................2016Tanda Tangan,

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

(Nama Lengkap Ketua Tim)

Bersama ini kami lampirkan :

1. Fotocopy kartu tanda mahasiswa/pengenal yang berlaku

*)Formulir ini boleh diperbanyak/dicopy

PANITIA GEBYAR HUT PERTAMINA 59Sekretariat : Kantor SPP.PWK, Komplek Gedung PatraGraha Telp : (0282) 509898 Fax : (0282)509897 2Jalan MT. HaryonoLomanisCilacapCp : Sunaryo Adi Putra – 0815 9574 413 Onward Andika – 0813 9111 5046

Foto3x4