Formulir-pendaftarn-bits-1.doc

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KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI POLITEKNIK NEGERI MALANG HIMPUNAN MAHASISWA TEKNIK SIPIL Jalan Soekarno Hatta No.9 Malang 65141 Telepon (0341) 404424 – 404425 Fax (0341) 404420 http://www.polinema.ac.id

Formulir Pendaftaran BITS Identitas diri a. Nama Lengkap b. Prodi c. NIM/Kelas d. No. Telp/HP e. Alamat Asal f. Alamat Tinggal Sekarang g. Pilihan divisi

:……………………………………………………………. : ……………………………………………………………. : ……………………………………………………………. :……………………………………………………………. :……………………………………………………………. :……………………………………………………………. : a) DIVISI LKTI/PKM b) DIVISI KJI KBGI c) DIVISI INOVASI Malang, ______________2019 Peserta,

(……………………………..)

CP : Syafira Oktaviani (081234512072) 2 MRK 4 M. Iqbal (085741934467) 3 MRK 5

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