No: __________

FORMULIR KELUHANGrievance Form

Nama/ Name : ______________________________

Alamat/ Address : __________________________ ______________________________________Telp: ___________

Tandatangan/ Signature : ______________________

Tanggal/ Date : ______________________________

Diterima oleh/ Received by : ______________________

Tanggal/ Date : ________________________________

Lokasi/ Location : ______________________________

Tanggapan oleh/ Response due by : _______________

_____________________________________________

Uraian Keluhan/ Description of Grievance :

Apa yang diinginkan dari perusahaan untuk menyelesaikan masalah tersebut? / What is theproposed solution from company? :