Nama : ....................................................................................................................................

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

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

Asal Universitas : ....................................................................................................................................

Alamat Universitas : ....................................................................................................................................

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

No. Telepon/Fax : ....................................................................................................................................

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

DATA PESERTA

Mahasiswa 1

a. Nama :.........................................................................................

b. Tempat, Tanggal Lahir :.........................................................................................

c. Jenis Kelamin :.........................................................................................

d. Jurusan :.........................................................................................

e. Nomor Induk Mahasiswa :.........................................................................................

f. No. Telepon/HP :.........................................................................................

g. E-mail :.........................................................................................

Foto

3x4

FORMULIR PENDAFTARAN

NATIONAL PAPER COMPETITION

CIVILWEEK 2020

Mahasiswa 2

a. Nama :.........................................................................................

b. Tempat, Tanggal Lahir :.........................................................................................

c. Jenis Kelamin :.........................................................................................

d. Jurusan :.........................................................................................

e. Nomor Induk Mahasiswa :.........................................................................................

f. No. Telepon/HP :.........................................................................................

g. E-mail :.........................................................................................

Mahasiswa 3

a. Nama :.........................................................................................

b. Tempat, Tanggal Lahir :.........................................................................................

c. Jenis Kelamin :.........................................................................................

d. Jurusan :.........................................................................................

e. Nomor Induk Mahasiswa :.........................................................................................

f. No. Telepon/HP :.........................................................................................

g. E-mail :.........................................................................................

Dosen Pembimbing

a. Nama :.........................................................................................

b. Tempat, Tanggal Lahir :.........................................................................................

c. Jenis Kelamin :.........................................................................................

d. NIP :.........................................................................................

e. Bidang Keahlian :.........................................................................................

f. No. Telepon/HP :.........................................................................................

g. E-mail :.........................................................................................

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PERNYATAAN KEIKUTSERTAAN

Yang bertanda tangan dibawah ini :

a. Nama :......................................................................................................................

b. Tempat, Tanggal Lahir :......................................................................................................................

c. Asal Universitas :......................................................................................................................

d. Alamat Universitas :......................................................................................................................

:......................................................................................................................

e. Kode Pos Universitas :......................................................................................................................

f. Nomor Induk Mahasiswa :......................................................................................................................

g. Jurusan/Prodi :......................................................................................................................

h. Alamat Mahasiswa :......................................................................................................................

:......................................................................................................................

i. No. Telepon/HP :......................................................................................................................

Mewakili tim saya yang beranggotakan

Dosen Pembimbing :......................................................................................................................

Mahasiswa :(1) .................................................................................................................

(2) .................................................................................................................

(3) .................................................................................................................

Dengan ini, saya menyatakan telah mendaftarkan diri sebagai peserta National Paper Competition

CIVILWEEK UNS 2020 dan bersedia mengikuti semua peraturan yang telah diterapkan.

…………………, ……. ………………………….. 2020

Menyetujui,

Ketua Jurusan/Bidang Kemahasiswaan Ketua Tim

( ) ( )

LEMBAR PERNYATAAN ORISINALITAS KARYA NATIONAL PAPER COMPETITION

CIVILWEEK 2020

Yang bertanda tangan di bawah ini :

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

NIM : ....................................................................................................................................

Jabatan : ....................................................................................................................................

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

NIM : ....................................................................................................................................

Jabatan : ....................................................................................................................................

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

NIM : ....................................................................................................................................

Jabatan : ....................................................................................................................................

Judul Karya Tulis :

………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………

Menyatakan bahwa karya tersebut asli buatan sendiri, bukan jiplakan dan belum pernah menjuarai lomba

sejinis sebelumnya.

Pernyataan ini kami buat dengan sebenar-benarnya. Apabila dikemudian hari terbukti tidak benar, saya

bersedia menerima sanksi yang ditetapkan oleh pihak panitia LOMBA NATIONAL PAPER COMPETITION

2020.

…………………, ……. ………………………….. 2020

Ketua Kelompok,

( )

Materai

6000

LEMBAR PENGESAHAN NATIONAL PAPER COMPETITION

CIVILWEEK 2020

1. Nama Tim :......................................................................................................................

2. Judul Karya :......................................................................................................................

3. Ketua Tim :......................................................................................................................

a. Nama Lengkap :......................................................................................................................

b. NIM :......................................................................................................................

c. Jurusan/Fakultas :......................................................................................................................

d. Universitas :......................................................................................................................

e. Alamat Rumah :......................................................................................................................

f. E-mail :......................................................................................................................

g. No. HP :......................................................................................................................

4. Nama Anggota :(1) .................................................................................................................

(2) .................................................................................................................

5. Dosen Pembimbing

a. Nama Lengkap dan Gelar : .......................................................................................................

b. NIP : .......................................................................................................

…………………, ……. …………………………..

2020

Dosen Pembimbing Ketua Tim

………………………………………….. …………………………………………..

NIP. NIM.