Pkm-2019-5-bidang-publish-pendanaan-form-isian.docx

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Kop Institusi FORM ISIAN KONTRAK Program Kreativitas Mahasiswa (PKM) 5 Bidang Tahun 2019 *) untuk di isi oleh Rektor/Ketua/Direktur Perguruan Tinggi Negeri atau Kepala Lembaga Layanan Pendidikan Tinggi 1. Identitas Personal Nama Lengkap NIP Jabatan Alamat No. Tlp/HP Email Pribadi

: : : : : :

2. Identitas Instansi Kode PT / Kopertis Nama Lengkap Alamat Lengkap No. Tlp/Fax/HP Website

: : : :

Email Kemahasiswaan

:

No. NPWP Institusi (Lampirkan scan)

:

3. Data Bank Penerima Dana (wajib rekening Instansi bukan rekening pribadi) Nama Lengkap : Alamat Lengkap : No. Tlp/Fax/HP Nama Lengkap pemilik pada rekening koran / buku Nomor Rekening Aktif tabungan (Lampirkan scan)

: :

....................,.....................2019

(...........................................) Scan Form Isian Kontrak dan lampiran (NPWP dan Rekening Koran) dikirim ke [email protected]

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