Formulir Isian Kontrak Penelitian Dan Pengabdian Kepada Masyarakat.doc

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Formulir Isian Kontrak Penelitian Dan Pengabdian Kepada Masyarakat

FORMULIR ISIAN I. Data & Indentitas : 1. Nama Lengkap (dengan gelar)

: Drs. Djoko Hirtono SSTF,M.Si

2. NIP.

: 1957 092 632

3. Jabatan

: Rektor/Ketua/Direktur

4. Nama PTS

: Akademi Kebidanan Wijaya Kusuma Malang

5. Alamat PTS

: Jl. Raya Tlogowaru Kedungkandang

Kota/Kabupaten/Kode Pos

: Malang / 65133

6. No. Telp. Kantor & HP

: 0341-7500328

7. Alamat Email Resmi

: wjksm16.gmail.com

8. No. NPWP Institusi

: 02.476.317.9-652.000

II. Data Bank Penerima Dana → (harus rekening Institusi bukan rekening pribadi) 1. Nama Bank

: Mandiri

2. Alamat Bank/ No. Telp.

: Jl. Merdeka Barat No. 1 Kota Malang – Jawa Timur / 0341 (7500328)

3. Nama yang tercantum pada Rekening koran/buku tabungan 4. Nomor Rekening (Lampirkan fotocopy)

: Akademi Kebidanan Wijaya Kusuma Malang : 144-001212782-2 Malang,

Maret 2019

(Drs. Djoko Hirtono. SSTF,M.Si) NIP : 1957 092 632

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