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ISIAN DATA UMKM

KABUPATEN KUDUS
1. NAMA :.....................................................................................................
2. NIK :.....................................................................................................
3. ALAMAT :.....................................................................................................
DESA :.....................................................................................................
KECAMATAN :.....................................................................................................
4. NAMA USAHA :.....................................................................................................
5. JENIS USAHA :.....................................................................................................
6. NO. HP :.....................................................................................................
7. EMAIL :.....................................................................................................
8. LEGALITAS/IZIN USAHA :.....................................................................................................
9. TENAGA KERJA :.....................................................................................................
10. KAPASITAS USAHA/BLN :.....................................................................................................
11. OMZET /THN :.....................................................................................................
12. ASSET :.....................................................................................................
13. PERMASALAHAN YANG
DIHADAPI :.....................................................................................................
.....................................................................................................
.....................................................................................................
14. LAMPIRAN YG DIPENUHI :
1. Surat permohonan bantuan hibah
2. Fotokopi ktp
3. Kwitansi, satu bermaterai
4. Fotocopy rekening bank aktif
5. Fotocopy legalitas usaha
6. Rencana penggunaan bantuan (rab)

Kudus, .....................................2020
Pemohon,

................................................
Rencana Penggunaan Bantuan
No Uraian Satuan Volume Jumlah

Kudus, .....................................2020
Pemohon,

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