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Formulis pengaduan
- 1. FORMULIR PENGADUAN MASYARAKAT NO: ……………………………….. Nama : ............................................................................................................. Alamat : ............................................................................................................. ............................................................................................................. ............................................................................................................. Nomor Telepon : ............................................................................................................. Pekerjaan : ............................................................................................................. Hal Yang diadukan : ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. Arjasa, …………….20…. Pengadu, (…………………………………)
- 2. TANDA BUKTI PENGADUAN NO: ……………………………….. Telah diterima Pengaduan dari: Nama : ............................................................................................................. Alamat : ............................................................................................................. ............................................................................................................. ............................................................................................................. Rincian Pengaduan : ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. ............................................................................................................. Arjasa, …………….20…. Petugas, (…………………………………)