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LAPORAN PELAKSANAAN TUGAS

1. Dasar Penugasan : Surat Tugas 800/….../PKM.NGR/……/2019


2. Nama Petugas : 1.....................................................................
2.....................................................................
3. Tujuan Perjalanan : ......................................................................
4. Tanggal Perjalanan : ......................................................................
5. Maksud Perjalanan : Pendataan PIS - PK
6. Hasil Pelaksanaan / Kesimpulan:
...........................................................................................................................
...........................................................................................................................
No Nama KK Alamat/Rt/Rw Ket

Nagreg, .....................................2019

Pejabat yang dikunjungi Petugas :

1.

( ..........................................)

2.

(..........................................) (...........................................)

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