8/17/2019 Formulir BOS 06a Dan 06b

1/2

Formulir BOS-6A

LEMBAR PENCATATAN MASYARAKAT

1. Identita Pengadu

a. Nama : ....................................................................................................................

 b. Alamat : ....................................................................................................................  ....................................................................................................................

2. Tanggal Terima Pengaduan : ..............................................................................................

3. Loa!i "e#adian

a. $T%$&%'u!un : ..........................................................................................................

 b. 'e!a%"elura(an : ..........................................................................................................

). "abu*aten%"ota : ..........................................................................................................

d. Pro+in!i : ..........................................................................................................

,. raian Pengaduan................................................................................................................................................................................................................................................................................................................................................................................................................................................

. Tanggal Pen/elidian 'ilauan : .....................................................................................

6. Pen/elidi : ......................................................................................................................

0. Temuan :................................................................................................................................................................................................................................................................................................

. "e*utu!an%$eomenda!i :................................................................................................................................................................................................................................................................................................

. Pela!anaan "e*utu!an

................................................................................................................................................

................................................................................................................................................

1. Tanggal *emberita(uan e*ada Pengadu tentan e*utu!an%dan *ela!anaan e*utu!an :

11. 'oumen /ang diterima :

................................................................................................................................................

................................................................................................................................................

Pealongan4 31 5aret 216

5ela*oran :

"e*ala S5" Negeri 3 Pealongan

Tusriyati, S.Pd.

 NIP 1612016326

8/17/2019 Formulir BOS 06a Dan 06b

2/2

Formulir BOS-6B

LEMBAR PENCATATAN MASYARAKAT

1. Identita! Penan/a % Pemberi Saran

a. Nama : .................................................................................................................

 b. Alamat : .................................................................................................................  .................................................................................................................

2. Tanggal Penerimaan Pertan/aan % Saran : .............................................................................

3. raian Pertan/aan % Saran :................................................................................................................................................................................................................................................................................................................................................................................................................................................

,. Penerima Pertan/aan % Saran : ...........................................................................

. Tinda Lan#ut Saran :................................................................................................................................................................................................................................................................................................................................................................................................................................................

Pealongan4 31 5aret 216

5ela*oran :

"e*ala S5" Negeri 3 Pealongan

Tusriyati, S.Pd.

 NIP 1612016326