YAYASAN PENDIDIKAN “ NURUSSA’ADAH AL A’LA”

SEKOLAH MENENGAH KEJURUAN

BILINGUAL BOARDING SCHOOL
NUSA BANGSA
ilmu teruji, akhlak terpuji, cerdas, trampil, dan mandiri
Jl . Teguhan Wringinjajar telp. (024) 70782104, Wringinjajar kec. Mranggen, Kab. Demak 59567

LEMBAR PENCATATAN PENGADUAN MASYARAKAT

1. Identitas Pengadu
a. Nama : ..............................................................................................................
b. Alamat : ..............................................................................................................

2. Tanggal Terima Pengaduan

3. Lokasi Kejadian
a. RT/RW/Dusun : ..................................................................................................
b. Desa/Kelurahan : ...................................................................................................
c. Kabupaten/Kota : ...................................................................................................
d. Provinsi :
4. Uraian Pengaduan :
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5. Tanggal Penyelidikan dilakukan : .............................................................................
6. Penyidik : ...................................................................................................
7. Temuan :
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8. Keputusan/Rekomendasi :
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9. Pelaksanaan Keputusan
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10. Tanggal pemberitahuan kepada pengadu tentang keputusan/dan pelaksana keputusan :
11. Dokumen yang diterima :
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Demak, 31 Maret 2019

Melaporkan :
Kepala SMK Nusa Bangsa
Kab/Kota Demak

Hayyin Ulfa Faza, S. Pd