Form Pengembalian Dana Binus Terisi [PDF]

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FM-BINUS-AP-FBK-20/V2R3



SURAT PERMOHONAN PENARIKAN DANA (FUND REQUEST WITHDRAWAL LETTER) No.236 Yth. (To) Layanan Keuangan Mahasiswa (Student Financial Services) Di Jakarta/Bandung/Malang (In Jakarta/Bandung/Malang) Dengan Hormat, (Dear Sir or Madam) Saya calon Mahasiswa dengan identitas (Hereby I declare the identity mentioned): No. Pendaftaran/NIM/Grade (No. Registration/ID Number/Grade) : 07162464775/2502017042/Undergraduate Nama (Name) : Muhammad Zaydan Athallah Alamat (Address) : Perumahan Duren Sawit Baru Blok A10 No.13 Telepon/ HP (Phone/ Mobile Number) : 0218620037/087786390240 Program (Program) : Computer Science (Would request to withdraw the fund that have been deposited to BINUS UNIVERSITY in order to I‘m accepted in) Diterima di PTN (Accepted by PTN)Tidak lulus SMTA (Not Graduated from SMTA) Diisi bila diterima di PTN/ tidak lulus SMTA (Filled if accepted in PTN/not graduated from SMTA) Nama PTN atau Nama SMTA (PTN Name or SMTA Name) : Institut Teknologi Sepuluh Nopember Jurusan PTN/ Jenjang Studi (PTN Major/ Study level) : Teknik Informatika Alamat (Address) : Jl. Teknik Kimia, Keputih, Kec. Sukolilo, Kota SBY, Jawa Timur 60111 Adapun rincian dana tersebut berasal dari (The detail of the fund derived from): ❑ Pembayaran Biaya Kuliah (Payment of College Fee) Rp. 19.800.000,❑ Pembayaran Laboratorium (Payment of Laboratory) Rp. 2.600.000,❑ Rp. 17.500.000,Pembayaran DP3 (Payment of Contribution) ❑ Pembayaran Seragam (Payment of Uniform) Rp. 0 ❑ Pembayaran Peralatan (Payment of Equipment) Rp. 9.000.000,Jumlah (Total) Rp. 48.900.000,Biaya Administrasi (Administration Fee) Rp. 5.000.000,Total yang dikembalikan (Total Refund) RP. 43.900.000,-



+ _



Untuk melengkapi surat permohonan ini, saya lampirkan (To complete this request form, I attach): Jika calon mahasiswa diterima sekaligus telah melakukan proses Daftar Ulang di Perguruan Tinggi Negeri (PTN) di bawah Kementerian Pendidikan dan Kebudayaan Republik Indonesia jenjang Strata 1 (S1) kecuali Universitas Terbuka dan PTN yang diselenggarakan oleh kementerian lainnya (If accepted and registered as student in PTN under the Ministry of Education and Culture of the Republic of Indonesia from level Strata-1 (S1), except Open University and PTN under the other Ministry): ❑ ❑



❑ ❑



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Fotokopi bukti keterangan lulus ujian PTN (asli harus ditunjukkan). (Photocopy of passed exam receipt in PTN (must show the original)). Fotokopi bukti pembayaran biaya kuliah di PTN (asli harus ditunjukkan) (Photocopy of payment for college fee receipt in PTN (must show the original)).



Fotokopi bukti penerimaan pendaftaran ulang atau Kartu Mahasiswa di PTN atau jadwal orientasi / kuliah (asli harus ditunjukkan). (Photocopy of acceptance re registration or Student Card or orientation / class schedule in PTN (must show the original)). Fotokopi cover buku tabungan orang tua calon mahasiswa. (Photocopy of the bankbook of prospective student parent).



Paket Mahasiswa Baru UNIVERSITAS BINA NUSANTARA yang telah diambil (Jaket Almamater, Jas Laboratorium, Binusian Flazz Card, Kartu Briefing, dll) (New Student BINUS UNIVERSITY Packet that have been taken (Almamater Jacket, Laboratorium coat, Binusian Flazz Card, Briefing Card, etc)



Jika penerima dana adalah pihak diluar orang tua calon mahasiswa, maka wajib melampirkan surat kuasa diatas materai, fotokopi KTP penerima kuasa dan fotokopi KTP pemberi kuasa. (If the recipient of the funds is outside parents of prospective student, it is obligatory to attach a letter of authority, photocopy of the recipient and principal identity card).



Jika mengikuti Ujian Nasional (UN) tetapi dinyatakan Tidak Lulus UN/SMTA (tidak memiliki SKHUN) (If follow of National Exam but not pass from National Test/SMTA/ haven’t SKHUN) :



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Surat Keterangan Tidak Lulus SMTA (dikarenakan tidak lulus Ujian Nasional SMTA /tidak memiliki SKHUN) dari Kepala Sekolah (asli) yang mencantumkan nama siswa, tempat & tanggal lahir, alamat, dan menggunakan kop surat sekolah yang bersangkutan.



(Information of not graduate from SMTA Letter (because of not pass from National test SMTA/ doesn’t have SKHUN) from Headmaster (original) at list consist of name, place and date of birth, address, and use header of its school) Fotokopi cover buku tabungan orang tua calon mahasiswa. (Photocopy of the bankbook of prospective student parent).



Paket Mahasiswa Baru UNIVERSITAS BINA NUSANTARA yang telah diambil (Jaket Almamater, Jas Laboratorium, Binusian Flazz Card, Kartu Briefing, dll) (New Student BINUS UNIVERSITY Packet that have been taken (Almamater Jacket, Laboratorium coat, Binusian Flazz Card, Briefing Card, etc)



Jika penerima dana adalah pihak diluar orang tua calon mahasiswa, maka wajib melampirkan surat kuasa diatas materai, fotokopi KTP penerima kuasa dan fotokopi KTP pemberi kuasa. (If the recipient of the funds is outside parents of prospective student, it is obligatory to attach a letter of authority, photocopy of the recipient and principal identity card).



Mohon dana tersebut di atas ditransfer ke rekening bank sebagai berikut (Please transfer the fund into the bank account below) : Nomor Rekening (Account Number) : 6330888111 Nama Pemilik Rekening (Name of Account owner) : Nokki Siska Rini Bank (Bank) : BCA Cabang (Branch) : KCP BUARAN RAYA (Jika rekening yang ditunjuk selain rekening atas nama orang tua, maka wajib melampirkan surat kuasa bermaterai) (If the designated account other is not the same with the prospective student parent name, then he/she must attach a letter of authority).



Demikian surat permohonan saya dan dengan terkabulnya permohonan ini berarti saya juga resmi mengundurkan diri sebagai mahasiswa di UNIVERSITAS BINA NUSANTARA. (Thus, ends my request letter, and I really thankful for approving my request. This also means that I am officially resigned as student in BINUS UNIVERSITY)



Jakarta/Bandung/Malang, 7 Juli 2021 Hormat saya (Respectfully yours), Diterima oleh (Receipt by)



Diperiksa oleh (Checked by)



Didatakan oleh (Encoded by),



(



) (__________)



(



(



Mahasiswa (Student)



Orang Tua (Parent)



( Staf Pemasaran (Marketing Staff)



)



)



Kasubbir LKM (Student Financial Services Section Head)



)



Staf LKM (LKM Staff)



………………………………………… …………………………………gunting disini (cut here) ……………………..………



Menyetujui (Approval), (



)



Manager SSC/Operations/SLS (SSC/Operations/SLS Manager)



………..…………….…………



Telah diterima formulir penarikan dana dari (Have been accepted the form of fund withdrawal from): No. Pendaftaran/NIM/Grade (No. Registration/ID Number/Grade) : 07162464775/2502017042/Undergraduate Nama (Name) : Muhammad Zaydan Athallah Total dana yang akan ditarik (Total fund withdraw) : Rp. 43.900.000,Proses pengembalian dana satu (1) bulan terhitung sejak formulir Penarikan Dana diserahkan ke Admisi. Refund process is one (1) month starting from the withdrawal form submitted to Admission).



Jakarta/Bandung/Malang, 7 Juli 2021.



( ) Catatan (Note): - Apabila lewat dari tanggal yang ditentukan, dana belum diterima, hubungi 021-29779100 ext 7084 (Alam Sutera), 022-20568888 ext 7822 (Bandung), 021-29285598 ext 7918 (Bekasi), 021-5345830 ext 1183 (Kemanggisan), 0341-3036969 ext. 7533 (Malang) (If expired from the date determined, the fund haven’t accepted yet, please contact 021-29779100 ext 7084 (Alam Sutera), 022-20568888 ext 7822 (Bandung), 02129285598 ext 7918 (Bekasi), 021-5345830 ext 1183 (Kemanggisan), 0341-3036969 ext. 7533 (Malang)