FORMULIR KONSULTASI BANTUAN HUKUM

I. DATA PEMOHON / KLIEN

1. Nama : ................................................................
2. Tempat / Tanggal lahir : ................................................................
3. Jenis Kelamin : ................................................................
4. Kawin / belum kawin / duda / janda : ................................................................
5. Tempat tinggal (Alamat) : ................................................................
Kelurahan / Desa : ................................................................
Kacamatan : ................................................................
Kabupaten / Kota : ................................................................
6. Pendidikan : ................................................................
7. Pekerjaan : ................................................................

II. Pelaksanaan konsultasi hukum (tanggal/bulan/tahun) .

.................................................................................................................................................
.................................................................................................................................................

III. Uraian Singkat Pokok Masalah san Latar Belakang.

.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

IV. Nasihat yang diberikan Konsultan termasuk Aspek Yuridisnya.

.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

V. Hasil akhir konsultasi.

.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

VI. Kesan konsultas atas tingkat pengetahuan / kesadaran hukum pemohon.

.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
VII. Pemohon / Klien
Nama : .........................................................................................................
Tandan Tangan : .........................................................................................................

VIII. Konsultan Hukum

Nama : .........................................................................................................
Tandan Tangan : .........................................................................................................

..................,.....................................20...
Mengetahui,

(nama OBH)
Direktur