FORMULIR PENGADUAN MASYARAKAT

NO : ....................................................................

Nama : ...........................................................................................
Alamat : ...........................................................................................
...........................................................................................
...........................................................................................
No. Telepon : ...........................................................................................
Pekerjaan : ...........................................................................................
Hal Yang Diadukan : ...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................

Makassar, ......................... 20.......

Pengadu,

(................................................)

Keterangan :
- Dilampirkan Foto Copy KTP

PENGADILAN TATA USAHA NEGARA MAKASSAR

Jl. Raya Pendidikan No. 1 Makassar
email : makassar@ptun.org
situs website : www.ptun-makassar.go.id
 TANDA BUKTI PENGADUAN
NO : ....................................................................

Telah diterima Pengaduan dari :

Nama : ...........................................................................................
Alamat : ...........................................................................................
...........................................................................................
...........................................................................................
Rincian Pengaduan : ...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................

Makassar, ........................ 20.......

Petugas,

(................................................)

PENGADILAN TATA USAHA NEGARA MAKASSAR

Jl. Raya Pendidikan No. 1 Makassar
email : makassar@ptun.org
situs website : www.ptun-makassar.go.id