MINISTRY OF RESEARCH, TECHNOLOGY AND HIGHER EDUCATION

UNIVERSITY OF BRAWIJAYA

FACULTY OF MEDICINE
Veteran Street Malang 65145
Telp. +62 341 579117, 567192, Fax. +62 341 - 564755
E-Mail: sekr.fk@ub.ac.id
http://www.fk.ub.ac.id

CERTIFICATE OF STUDENT STATUS

NO :

/UN10.7/AK/2016

To whom it may concern,

This document certifies the following information about the student current status at the university of
Brawijaya, as of 16 May 2016. The student below is registered for the academic year 2015/2016:
Student details
Name

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

Student number

: ....

Date of Birth

: ....

Address

: ....

Programme

: Specialist of Urology

Class/level

: ....

This certificate is provided as evidence that the above student is registered at the University of
Brawijaya for the period shown.

Malang,
On behalf of the Head of Administration,
Chief of Academic Division,

DEWI SUSANTI, SE.M.SA

NIP. 197212222005012002