formulir pengaduan
Post on 15-Dec-2015
8 Views
Preview:
DESCRIPTION
TRANSCRIPT
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.
top related