• Kontak
  • (0536) 3221645
• Jl. Diponegoro No. 60 Palangka Raya
• Senin s/d Jum'at, Pukul 08.00-15.30 WIB

PERMOHONAN SURAT IZIN PENELITIAN

• Surat akan dikirim melalui Whatsapp atau email.
• Lampiran dikirim dalam format .pdf
• Untuk identitas pemohon dapat berupa: KTM atau KTP
• Dimohon mengisi formulir dengan menggunakan "HURUF KAPITAL" kecuali alamat e-mail.

• Letters will be sent via Whatsapp or email.
• Attachment are submitted in .pdf
• For applicant Identity can be: Student ID Card atau ID Card
• Please use "CAPITAL LETTERS" to fill the form expcept the e-mail address

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NAMA LENGKAP (FULL NAME) *

NOMOR TELEPON (PHONE NUMBER) *

EMAIL *

TEMPAT LAHIR (PLACE OF BIRTH) *

TANGGAL LAHIR (DATE OF BIRTH) *

KEWARGANEGARAAN (NATIONALITY) *

NIM (Student Undentification Number) *

UNIT KERJA TIM SURVEY / PENELITI (WORK UNIT SURVEYOR TEAM / RESEARCHER) *

LEMBAGA/PERGURUAN TINGGI (INSTITUE/COLLEGE) *

LOKASI PENELITIAN SPESIFIK (PESEARCH LOCATION) *

DURASI PENELITIAN (Research DURATION) *

JUDUL PENELITIAN (RESEARCH TITLE) *

Kartu Identitas (Identity Card) *

Instansi Yang Mengeluarkan Surat (Institution that issued the letter) *

Nomor Surat (Number of The Letter) *

Tanggal Surat (Date of The Letters) *

Nomor Surat (Number of The Letter) *

Surat Pengajuan Dari Kampus (Submission Letter from College) *

Proposal Penelitian (Research Proposal) *

Simpan