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Panduan_Pelaksanaan_Penelitian_dan_PPM_Edisi_X_2016

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Lampiran 28.2 Format Halaman Pengesahan Proposal Program Hi-Link<br />

HALAMAN PENGESAHAN PROGRAM HI-LINK<br />

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

2. Ketua Tim Pengusul<br />

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

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

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

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

e. Program Studi : ....................................................................................<br />

f. No. HP : ....................................................................................<br />

g. E-mail : ....................................................................................<br />

3. Mitra Industri<br />

a. Nama Industri Mitra : ....................................................................................<br />

b. Nama Direktur : ....................................................................................<br />

c. Alamat : ....................................................................................<br />

d. Telpon/Faks Kantor : ....................................................................................<br />

e. No. HP : ....................................................................................<br />

f. E-mail : ....................................................................................<br />

4. Pemda<br />

a. Nama Lembaga Pemda : ....................................................................................<br />

b. Nama Kepala Lembaga : ....................................................................................<br />

c. Alamat : ....................................................................................<br />

d. Telpon/Faks Kantor : ....................................................................................<br />

e. No. HP : ....................................................................................<br />

f. E-mail : ....................................................................................<br />

5. Total Dana (3 tahun) : Rp .................................<br />

a. Dana DRPM : Rp .................................<br />

b. Dana Mitra Industri : Rp .................................<br />

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

6. Dana Tahun I : Rp .................................<br />

a. Dana DRPM : Rp .................................<br />

b. Dana Mitra Industri : Rp .................................<br />

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

Mengetahui<br />

Ketua LPM/L<strong>PPM</strong> *<br />

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

(Nama Lengkap)<br />

NIP/NIK<br />

Direktur<br />

Mitra Industri<br />

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

Kota, tanggal bulan tahun<br />

Ketua Tim Pengusul<br />

Tanda tangan<br />

(Nama Lengkap)<br />

NIP/NIK<br />

Bupati/Walikota/<br />

Ketua Bappeda/Kepala SKPD<br />

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

(Nama Lengkap)<br />

(Nama Lengkap)<br />

NIP<br />

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

PEDOMAN PENELITIAN DAN PENGABDIAN KEPADA MASYARAKAT EDISI X 503

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