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.