Surveyor: .
: ...
2. Usia
: ....................................................... Tahun
3. Jabatan
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4. Alamat
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5. Aset Wisata di Desa : .......................................................
Kec
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Kab
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Propinsi : .......................................................
a. Wisata Alam ( Gua/Pantai/Air Terjun/Bukit/Hutan/dll )
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b. Wisata Buatan ( Taman/Water Boom/Water Park/dll )
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c. Bangunan Bersejarah ( Monumen/Masjid/Tugu/Gereja/dll )
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d. Wisata Ziarah ( Makam / Petilasan )
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e. Wisata Pahlawan ( Rumah kelahiran Pahlawan/dll )
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f. Kesenian
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Hari/Tgl:.
Surveyor: .
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g. Kerajinan
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h. Industri Kuliner
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i. Wisata Agraris ( Pertanian & Perkebunan )
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j. Wisata Pendidikan ( Pelatihan )
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k. Flora & Fauna.
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l. Makanan & Minuman + wadah Untuk Menyajikannya ( Tradisional )
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m. Home Stay ( Penginapan )
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n. Transportasi ( Delman/Becak/dll )
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o. Fasilitas ( Binatu/ olahraga/ dll )
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Hari/Tgl:.
Surveyor: .
5. ............................................