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