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 :.....................................................................................................
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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,
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Rencana Penggunaan Bantuan
No Uraian Satuan Volume Jumlah
Kudus, .....................................2020
Pemohon,
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