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FORMULIR PENDAFTARAN LOMBA KARYA TULIS ILMIAH MAHASISWA TINGKAT NASIONAL NATIONAL AVICENA COMPETITION 2015 Asal Universitas : ............................... Nama lengkap : ............................... Jenis kel. : L/P (*) Alamat : ............................... Tempat/ Tanggal lahir : ............................. No. telp/ Hp : ............................... Prestasi : ............................... ............................... ............................... ............................... Konsumsi : Vegetarian / Non Vegetarian (*) Keterangan: (*) : Coret yang tidak perlu Foto 3 X 4

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FORMULIR PENDAFTARAN LOMBA KARYA TULIS ILMIAH MAHASISWA TINGKAT NASIONALNATIONAL AVICENA COMPETITION 2015Asal Universitas : ...............................................................................Nama lengkap : ...............................................................................Jenis kel. : L/P (*)Alamat : ...............................................................................Tempat/ Tanggal lahir : No. telp/ Hp : ...............................................................................Prestasi : ...............................................................................................................................................................................................................................................................................................................................Konsmsi : !egetarian / Non !egetarian (*)Keterangan: (*) : "oret #ang ti$ak perl %asing&masing peserta mengisi 'ormlir #ang (er(e$a. )ormlir ini $apat $iper(an#ak sesai ke(than. Pengmplan 'ormlir $isertai $engan * lem(ar 'otokopi kart mahasis+a $an * (ah 'oto (erkran ,-. ('oto lain selain ntk $itempel). Penlisan 'ormlir menggnakan hr' kapital.)oto, / .