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PEMERINTAH KABUPATEN MANGGARAI

DINAS KESEHATAN
JalanAhmad Yani No. 11 Telp. (0385) 21120 Ruteng

FORMULIR PENGADUAN MASYARAKAT

Nama Pelapor :............................................................

Jenis Kelamin : ............................................................

Usia : ............................................................

No. KTP : ............................................................

No. Telp/Hp : ............................................................

Alamat Email : ............................................................

Materi yang dilaporkan : ............................................................

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Ruteng, ......,.......................Tahun........

TTD :

Nama :

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