Formulir Pengaduan
1
FORMULIR PENGADUAN MASYARAKAT Nomor : ……………………………….. *) Nama : ............................................................................................................. Alamat : ............................................................................................................. ............................................................................................................. ............................................................................................................. Nomor Telepon : ............................................................................................................. E-mail : ……………………………………………………………………….. Pekerjaan : ............................................................................................................. Hal Yang diadukan : ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... …………………………, …………….20…. Pelapor, (…………………………………) *) Diisi oleh petugas meja informasi dan pengaduan masyarakat Catatan : Identitas pelapor diisi selengkapnnya dan sebenar-benarnya, karena kami akan menjamin keamanan dan kerahasiaan identitas pelapor.
-
Upload
mutiaralido -
Category
Documents
-
view
8 -
download
0
description
ok
Transcript of Formulir Pengaduan
FORMULIR PENGADUAN MASYARAKAT
Nomor : ……………………………….. *)
Nama : .............................................................................................................
Alamat : .............................................................................................................
.............................................................................................................
.............................................................................................................
Nomor Telepon : .............................................................................................................
E-mail : ………………………………………………………………………..
Pekerjaan : .............................................................................................................
Hal Yang diadukan :
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
…………………………, …………….20….
Pelapor,
(…………………………………)
*) Diisi oleh petugas meja informasi dan pengaduan masyarakat
Catatan : Identitas pelapor diisi selengkapnnya dan sebenar-benarnya, karena kami akan menjamin
keamanan dan kerahasiaan identitas pelapor.
