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FORMULIR PENGADUAN MASYARAKAT
Nomor : ……………………………….. *)
Nama : .............................................................................................................
Alamat : .............................................................................................................
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Nomor Telepon : .............................................................................................................
E-mail : ………………………………………………………………………..
Pekerjaan : .............................................................................................................
Hal Yang diadukan :
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…………………………, …………….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.