FORMULIR PENDAFTARAN

DATA DIRI PESERTA

Nama Tim

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

Nama Jembatan

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

Nama Perguruan Tinggi

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

Alamat Perguruan Tiggi

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

Telepon

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

Faksimile

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

E-mail

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

Dosen Pembimbing
Nama Lengkap

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

NIP

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

Alamat Kantor

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

Alamat Rumah

:.......................................................................................................
FOTO 3X4

.........................................................................................................
Telepoon/Faksimile/HP

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

E-mail

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

Peserta 1
Nama Lengkap

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

NIM

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

Jurusan/Prodi/Semester

:.....................................................................
FOTO 3X4

Alamat Rumah

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

Telpon/Faksimile/HP

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

Peserta 2
Nama Lengkap

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

NIM

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

Jurusan/Prodi/Semester

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

Alamat Rumah

Telpon/Faksimile/HP

FOTO 3X4

Peserta 3
Nama Lengkap

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

NIM

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

Jurusan/Prodi/Semester

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

Alamat Rumah

Telpon/Faksimile/HP

FOTO 3X4

FORMAT LAMPIRAN 1C
LEMBAR PENGESAHAN
BRIDGE DESIGN FESTIVAL 2016

Nama Tim
Nama Jembatan

:................................................................................................
FOTO 3X4
:................................................................................................
DITEMPEL
FOTO 3X4
DITEMPEL

Nama Perguruan Tinggi

Nama Dosen Pembimbing
Nama Anggota Tim
Nama, NIM

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

Nama, NIM

Nama, NIM

Alamat Perguruan Tinggi

Telepon
Faksimile
E-mail

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

Dengan ini menyatakan bahwa :

1 Mematuhi dan melaksanakan panduan Kompetisi Bridge Design Festival 2016;
2 Menjaga kebersihan dan ketertiban selama pelaksanaan kompetisi; dan
Mematuhi segala peraturan yang dibuat oleh Panitia Kompetisi Bridge Design Festival
2016.
, ..2016
Mengetahui,
Dosen Pembimbing

Ketua Tim

(...)
................)
NIP.

FORMAT LAMPIRAN 1D
SURAT PERNYATAAN
Yang bertanda tangan dibawah ini,
Nama Tim

Institusi Universitas Asal

Alamat Universitas Asal

Nama Dosen Pembimbing

NIP/TTL

Anggota Tim

Nama
NIM
2 Nama
NIM
2 Nama

:
:
:
:
:

(.
NIM

NIM

Dengan ini menyatakan bahwa:

Dalam karya tulis ilmiah ini, kami menjamin tidak menjiplak/menyadur/meringkas/
memplagiat dari karya siapapun atau pendapat yang telah ditulis atau dipublikasikan orang lain,
kecuali secara tertulis dengan jelas dicantumkan dalam daftar pustaka.
Demikian pernyataan ini kami buat secara sadar dan tanpa adanya tekanan dari pihak lain.
.............. , ...................... 2016
Yang membuat pernyataan,

Mengetahui,
Dosen Pembimbing

(...)
................)
NIP.

Ketua Tim

(.
NIM