Ministry of Education And Culture

University of Malikussaleh
Medical School
Jl. H. Meunasah Uteunkot Cunda Lhokseumawe
Nanggroe Aceh Darussalam Indonesia
Phone : +645 40549
e-mail : info@pspd.unimal.ac.id

Kementerian Pendidikan Dan Kebudayaan

Universitas Malikussaleh
Program Studi Pendidikan Dokter
Jl. H. Meunasah Uteunkot Cunda Lhokseumawe

Nanggroe Aceh Darussalam Indonesia

Phone : +645 40549
e-mail : info@pspd.unimal.ac.id

CEK LIST PENGAMBILAN IJAZAH

Nama
NIM
Fakultas/ Prodi
IPK
Judul Skripsi
Tanggal Lulus
Tanggal Wisuda

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

1. Penyerahan Skripsi:
A. Komisi Pembimbing / Penguji
Nama

B.
C.
D.
E.
F.
G.
H.

Tanggal

Tanda Tangan

1. ......................................................

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

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

2. ......................................................

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

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

3. ......................................................

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

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

4. ......................................................

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

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

Sekretaris Prodi
: dr. Cut Khairunnisa, M.Kes ...................
Perpustakaan Unimal
:.............................................. ...................
Perpustakaan Fakultas
: .............................................. ...................
Surat Bebas Pustaka Unimal : .................................................................
Pengambilan Toga
: ............................................. ...................
Semua Syarat Untuk Mengganti Ijazah sudah dipenuhi
Bendahara
:............................................. ...................

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

Reulet,..........................................
Ka.Biro Adm.Akademik

Arif Rahman, SA. MH

NIP. 19720331 200212 1 001

FORM LAPORAN DISTRIBUSI SKRIPSI

PROGRAM STUDI PENDIDIKAN DOKTER
Nama

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

Ministry of Education And Culture

University of Malikussaleh
Medical School
Jl. H. Meunasah Uteunkot Cunda Lhokseumawe
Nanggroe Aceh Darussalam Indonesia
Phone : +645 40549
e-mail : info@pspd.unimal.ac.id
Nim

Kementerian Pendidikan Dan Kebudayaan

Universitas Malikussaleh
Program Studi Pendidikan Dokter
Jl. H. Meunasah Uteunkot Cunda Lhokseumawe

Nanggroe Aceh Darussalam Indonesia

Phone : +645 40549
e-mail : info@pspd.unimal.ac.id

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

Judul Skripsi : ....................................................................................................................................

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

No

Tujuan

Tanggal

Distribusi

Terima

Penerima

Tanda Tangan

Pustaka
1

Universitas
Malikussaleh

Pustaka PSPD
UNIMAL

Dosen
Pembimbing

Mengetahui,
A.n Ketua PSPD
Sekretaris

dr. Cut Khairunnisa, M.Kes

NIP. 19820312 200912 2 004

Koordinator Pengelola Skripsi

PSPD

dr. Zubir, M.Biomed

NIP.19790804 200912 1 001