FORMULIR TANGGAPAN/MASUKAN MASYARAKAT

TERHADAP CALON ANGGOTA PPK

KABUPATEN PADANG PARIAMAN

.................................Februari 2018

Nomor : ...................................................
Sifat : ...................................................
Lampiran : ...................................................
Perihal : ...................................................
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Kepada Yth.
Ketua Tim Seleksi Calon Anggota PPK
Kabupaten Padang Pariaman Tahun 2018
di-
Tempat

1. Pelapor

a. Nama : ...............……………………………….......................
b. NIK : ...............……………………………….......................
c. Tempat/Tanggal Lahir : ...............……………………………….......................
d. Jenis Kelamin : ...............……………………………….......................
e. Pekerjaan : ...............……………………………….......................
f. Kewarganegaraan : ...............……………………………….......................
g. Alamat : ...............……………………………….......................
h. No.Telp/HP : ...............……………………………….......................
i. Fax : ...............……………………………….......................
j. E-mail : ...............……………………………….......................

2. Uraian tanggapan/masukan tentang calon :

A. Berintegritas, jujur, dan adil

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B. Tidak menjadi anggota politik 5 (lima) tahun terakhir
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 C. Bebas dari penggunaan narkoba
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D. Tidak pernah dipenjara
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E. Belum pernah menjabat 2 (dua) kali dalam jabatan yang sama (dua
periode)
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F. Tidak Berada dalam ikatan perkawinan degan sesama peyeleggara
pemilu
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3. Bukti-Bukti:

a. ………………………………………….......………………………………………………...
b. ………………………………………….......………………………………………………...
c. ………………………………………….......………………………………………………...
d. ....................................................................................................................

Saya menyatakan bahwa isi laporan ini adalah yang sebenar-benarnya dan saya
bersedia mempertanggung jawabkan dihadapan hukum.

Pelapor

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