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Formulir Pengajuan Cuti Kuliah

This document is a college furlough application form for BINUS Online Learning. It requests the student's personal details such as name, student ID number, department, address, contact details, reason for leave, and term of official furlough and planned return. The form must be submitted with full documentation and will be processed by the student services department to determine eligibility based on academic status and financial obligations. It requires final approval from the Dean of the student's faculty.

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Hendi Prasetya
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893 views2 pages

Formulir Pengajuan Cuti Kuliah

This document is a college furlough application form for BINUS Online Learning. It requests the student's personal details such as name, student ID number, department, address, contact details, reason for leave, and term of official furlough and planned return. The form must be submitted with full documentation and will be processed by the student services department to determine eligibility based on academic status and financial obligations. It requires final approval from the Dean of the student's faculty.

Uploaded by

Hendi Prasetya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FM-BINUS-AA-FRM-2.

106/R1

FORMULIR PERMOHONAN CUTI KULIAH


BINUS Online Learning
College Furlough Application Form
BINUS Online Learning

Nama : ………………………………………………………………………
Name
NIM : ………………………………………………………………………
Student ID Number
Jurusan : ………………………………………………………………………
Deparment
Alamat lengkap : ………………………………………………………………………
Address ………………………………………………………………………
………………………………………………………………………

Telepon – Rumah : ……………………..


Phone Number Home
– HP : ……………………..
Mobile Phone
– E-mail : ………………………………………………………………………
E-mail
Term cuti resmi : …………………………………………...tahun akademik ……..…/………...
Term of official furlough academic year
Term aktif kembali : ……………………………………………tahun akademik ………./…………..
Term of re-active academic year
Alasan
Reason : …………………………………………………………………………………….
……………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………

Jakarta,
Hormat saya, Petugas
Regards, Staff

Mahasiswa Nama
Student Name

Catatan :
Note
Formulir permohonan diajukan beserta bukti kelengkapan
Application Form submitted with full witness
FM-BINUS-AA-FRM-2.106/R1

Diisi oleh Layanan Mahasiswa :


Filled by Student Service

Tanda Tangan :
- Aktif Terakhir : ………………………………... Signature
Last active

- Sisa Masa Studi : ………………………………..


Study Period Left

- Jumlah term pernah Cuti Resmi : ………………………………..


Number of term which official furlough

- Status Peminjaman Buku di Perpustakan : ……………………………….


Book Loan Status

Rincian Pembayaran diisi oleh Layanan Mahasiswa


Payment detail filled by Student Service

Jenis Nilai Status Tanda Tangan


Item Amount Status Koord. Operasional:
………………….. ……………………. ………………….. Signature by section head
………………….. ……………………. ………………….. of Academic operational
………………….. ……………………. …………………..
………………….. ……………………. …………………..
………………….. ……………………. …………………..
………………….. ……………………. …………………..

Menyetujui / Menolak
Approve/reject
No :
No
Tgl :
Date

Dekan Fakultas …………………….


Dean Faculty of ……………………

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