1. Identitas Pengadu
a. Nama : .................................................................................
b. Alamat : .................................................................................
.................................................................................
3. Lokasi Kejadian
a. RT/R/Dusun : ...........................................................................
b. Desa/Kelurahan : ...........................................................................
. KPraobvui$nasit : ...........................................................................
en/Kota
*. Pen)elidik ............................................................................................
+. Temuan
...........................................................................................................
...........................................................................................................
8. Ke$utusan/Rekomendasi :
...........................................................................................................
...........................................................................................................
9. Pelaksanaan Ke$utusan
...........................................................................................................
...........................................................................................................
..................................... 2
0ela$orkan :
UP0 Prov/Kab/Kota/ekolah
........................................
5/28/2018 Formulir BOS-6A (Pengaduan) - slidepdf.com
http://slidepdf.com/reader/full/formulir-bos-6a-pengaduan 2/2