KOMISI PEMBERANTASAN KORUPSI REPUBLIK INDONESIA

Jl. HR. Rasuna Said Kav. C-1 Jakarta

Telp: 021-2557 8498, Faks: 021- 5290 5592
E-mail: informasi@kpk.go.id

FORMULIR PERMINTAAN INFORMASI

No. Registrasi (Diisi petugas)

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Nama

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Alamat

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Telepon
Pekerjaan

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Rincian Informasi yang Dibutuhkan

Alasan penggunaan informasi

Tanggapan/Keterangan (Diisi Petugas)

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Status Tindak Lanjut (Diisi petugas)

Cara Memperoleh Informasi

Melihat/membaca/mendengarkan/Mencatat**

Mendapatkan salinan informasi (hardcopy/softcopy)**

Diambil langsung

Kurir

Pos

E-mail

Faksimile

Cara Mengirimkan Informasi

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Jakarta, ..............................................
Petugas Pelayanan Informasi,

Pemohon Informasi,

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Keterangan:
* Pilih salah satu dengan memberi tanda ()
** Coret yang tidak perlu