data promovendus 2011
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DATA PROMOVENDUS Dilampiri ringkasan disertasi dalam bahasa Indonesia dan rekaman disertasi di CDRom A. B. DATA PRIBADI 1. Nama : .........................................................................(L/P) 2. Tempat & Tanggal Lahir : ................................................................................ 3. Pekerjaan di Indonesia Pangkat/Jabatan/Golongan NIP : ................................................................................ ................................................................................ …………………………………………………………. 4. Nama dan Alamat Instansi Asal/Perguruan Tinggi : ................................................................................ ................................................................................ ................................................................................ .....................................Telp.................................... 5. Alamat terakhir di Perancis : ................................................................................ ................................................................................ .....................................Telp.................................... 6. Alamat di Indonesia : 7. E-mail : ................................................................................ ................................................................................ .....................................Telp.................................... …………………………………………………………. PENDIDIKAN 1. Riwayat Pendidikan (dari lulus SMA/sederajat, sampai DOKTOR), sebutkan jangka waktu pendidikan dan nama sekolah/perguruan tinggi. ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ .........................................................................................................................................……............ ....................................…………………………………………………………………………................... Tanggal Promosi (soutenance) : Predikat (mention) : 2. Bidang Studi (program Doktor) : Spesialisasi : 3. Judul Disertasi (dalam bahasa Prancis dan terjemahannya dalam bahasa Indonesia) ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 4. Biaya Pendidikan (beri tanda √ atau lingkari jawaban yang benar dan lengkapi jawaban) • ( ) Pribadi ( ) Beasiswa • (…) Beasiswa dari Pemerintah Perancis/Indonesia, proyek …………………………………….. • (…) Beasiswa dari Perusahaan Perancis/Indonesia, sebutkan………………………………….. • Pengelola beasiswa di Perancis (SFERE/CROUS/EGIDE) atau………………………………… Beasiswa diberikan sampai studi selesai, mulai …………………….sampai …………………………. Atau (sebutkan) : …………………………………………………………………………………………… 5. Dosen Pembimbing, Direktur Labo. dan mereka yang telah banyak membantu/berperan dalam penulisan disertasi (kolom berikut dapat ditambah/dikurangi sesuai jumlah nama yang akan disampaikan). a. b. c. d. Nama (lengkap dengan gelar) : Membantu/berperan sebagai : Dosen Pembimbing Alamat : Nama (lengkap dengan gelar) : Membantu/berperan sebagai : Direktur Labo. Alamat : Nama (lengkap dengan gelar) : Membantu/berperan sebagai : Alamat : Nama (lengkap dengan gelar) : Membantu/berperan sebagai : Alamat : C. PUBLIKASI .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. CATATAN : Dibuat di .................................... - Coret yang tidak perlu - Bila diperlukan dapat menggunakan lembar tambahan Tanggal...................................... ( )
