Panduan_Pelaksanaan_Penelitian_dan_PPM_Edisi_X_2016
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Lampiran 26.2 Format Halaman Pengesahan Proposal Program IbW-CSR atau<br />

IbW-PEMDA-CSR<br />

HALAMAN PENGESAHAN<br />

PROGRAM IbW-CSR ATAU IbW-PEMDA-CSR<br />

1. Judul : ....................................................................................<br />

2. Perguruan Tinggi Pengusul : ....................................................................................<br />

a. Lembaga PT A (Nama, : ....................................................................................<br />

Alamat , Telp. Faks, E-mail) : ....................................................................................<br />

b. Lembaga PT B (Nama, : ....................................................................................<br />

Alamat , Telp. Faks, E-mail) : ....................................................................................<br />

3. Ketua Tim Pengusul<br />

a. Nama lengkap : ....................................................................................<br />

b. NIDN : ....................................................................................<br />

c. Jabatan/Golongan : ....................................................................................<br />

d. Perguruan tinggi : ....................................................................................<br />

4. Anggota Tim Pengusul<br />

a. Perguruan Tinggi (A) : Dosen ……orang, Mhs.....orang<br />

b. Perguruan Tinggi (B) : Dosen ……orang, Mhs.....orang<br />

c. Staf Pemda : ……orang<br />

d. Staf CSR : ……orang<br />

e. Staf Lembaga lain : ……orang<br />

5. Lokasi <strong>Pelaksanaan</strong> IbW-CSR atau IbW-PEMDA-CSR<br />

a. Nama Wilayah (Desa/Kec.) : ....................................................................................<br />

b. Kabupaten/Kota : ....................................................................................<br />

c. Propinsi : ....................................................................................<br />

6. Jangka Waktu <strong>Pelaksanaan</strong> : 3 tahun<br />

7. Biaya Total 3 Tahun : Rp .......................................<br />

8. Rencana Belanja Total : tahun ke- …… (I/II/III*), Rp ....................................<br />

a. Dikti : Rp .......................................<br />

b. CSR : Rp .......................................<br />

c. Pemda : Rp .......................................<br />

d. Sumber lain (apabila ada) : Rp .......................................<br />

Mengetahui,<br />

Ketua LPM/L<strong>PPM</strong> * PT (A)<br />

Cap <strong>dan</strong> tanda tangan<br />

(Nama Lengkap)<br />

NIP/NIK<br />

Kota, tanggal-bulan-tahun<br />

Ketua Tim Pengusul<br />

Tanda tangan<br />

(Nama Lengkap)<br />

NIP/NIK<br />

Ketua LPM/L<strong>PPM</strong> * Bupati/Walikota/ Direktur/Kepala<br />

PT (B) Ketua Bappeda CSR<br />

Cap <strong>dan</strong> tanda tangan Cap <strong>dan</strong> tanda tangan Cap <strong>dan</strong> tanda tangan<br />

(Nama Lengkap) (Nama Lengkap) (Nama Lengkap)<br />

NIP/NIK<br />

NIP<br />

* Disesuaikan dengan nama lembaga atau unit pengabdian kepada masyarakat di PT<br />

* Semua tanda tangan harus asli <strong>dan</strong> bukan hasil pemindaian<br />

PEDOMAN PENELITIAN DAN PENGABDIAN KEPADA MASYARAKAT EDISI X 458

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