:

FORMULIR PENGADUAN
Kota Mungkid, ................................... 20 ....

Kepada :

Nomor : ............................................. Yth. KEPALA DINAS PENANAMAN MODAL

Sifat : ................................................ DAN PELAYANAN TERPADU SATU PINTU
Lampiran : ................ KABUPATEN MAGELANG
Di -
Perihal : ............................................
KOTA MUNGKID

Yang bertanda tangan di bawah ini :

:
NAMA : ..............................................................................................................
ALAMAT : ..............................................................................................................
NO. TELEPON : ..............................................................................................................
NO. KTP ..............................................................................................................

Dengan ini kami sampaikan pengaduan atas permohonan izin usaha :

NAMA : .............................................................................................................
ALAMAT : ..............................................................................................................
JENIS IZIN : ..............................................................................................................
NOMOR : ..............................................................................................................
TANGGAL : .............................................................................................................

Adapun permasalahannya adalah sebagai berikut :

1. ............................................................................................................................................
............................................................................................................................................
2. ............................................................................................................................................
............................................................................................................................................
3. ............................................................................................................................................
............................................................................................................................................

Bersama ini kami lampirkan data-data pendukung sebagai berikut :

1. ...........................................................................................................................................
PENGADU :
PENERIMA ADUAN :
2. ...........................................................................................................................................
3. ...........................................................................................................................................
4. ...........................................................................................................................................
( ....................................)
( .................................. )
Demikian untuk menjadikan periksa dan atas perhatiannya disampaikan terima kasih.
 PEMERINTAH KABUPATEN MAGELANG
DINAS PENANAMAN MODAL
DAN PELAYANAN TERPADU SATU PINTU
Jl. Soekarno Hatta No.20 Telp (0293) 788249 Kota Mungkid (56511)
www.magelangkab.go.id

BERITA ACARA

Pada hari ini ................. tanggal ........................................................... Tahun ................ yang

bertanda tangan di bawah ini, telah melaksanakan rapat penyelesaian pengaduan masyarakat dan
pengecekan ke lokasi sebagai berikut :

Jenis izin & No. izin : ....................................................................................................................

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

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

Nama Perusahaan :

Pemilik izin :

Lokasi :

Jenis Usaha : `

Hasil penyelesaian pengaduan sebagai berikut :

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

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

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

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

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

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

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

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

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

Demikian Berita acara ini dibuat dengan sebenarnya untuk dapat dipergunakan sebagaimana
mestinya.

Mengetahui Nama Tanda Tangan

Pengelola/pemilik Ka. DPM PTSP
usaha
1. ........ ............. ..................
2. ...................... ..................

(AS. WIDYANTARA,SH) 3. ...................... ...................

( .......................... )
4. ...................... ...................
5. ...................... ...................
6. ...................... ....................
7. ...................... ....................
 SURAT PERNYATAAN

Yang Bertanda tangan di bawah ini saya :

Nama : ........................................................................................................
Tempat dan tanggal lahir : ........................................................................................................
Jenis kelamin : ........................................................................................................
Alamat Tempat Tinggal : ........................................................................................................
........................................................................................................
Letak Tempat usaha : ........................................................................................................
........................................................................................................
Jenis usaha : ........................................................................................................
........................................................................................................
Dengan ini menyatakan dengan sesungguhnya bahwa saya sebagai Pengelola/Pemimpin
Usaha menyatakan :
.........................................................................................................................................................
- ........................................................................................................................................................
- ........................................................................................................................................................
- ........................................................................................................................................................
- ........................................................................................................................................................
- ........................................................................................................................................................
- .........................................................................................................................................................
- .........................................................................................................................................................
- .........................................................................................................................................................
Demikian surat pernyataan ini saya buat dengan sesungguhnya tanpa ada paksaan dari pihak
manapun juga, dan apabila melanggar dari pernyataan tersebut, saya bersedia ditindak sesuai
peraturan perundang-undangan yang berlaku.

......................, ........................... 20 .....

Yang menyatakan

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

MENGETAHUI

CAMAT ....................................
Kades/Lurah ....................................

( .............................................) ( ........................................ )
SAKSI-SAKSI : JABATAN TANDA TANGAN :

1. .......................................... ............................................. 1. .................................

2. .......................................... .......................................... 2. .................................

3. .......................................... ........................................ 3. .................................

4. .......................................... ...................................... 4. .................................

5. .......................................... ...................................... 5. ...............................

6. .......................................... ....................................... 6. .................................

7. .......................................... ....................................... 7. .................................

8. .......................................... ......................................... 8. .................................

9. .......................................... ......................................... 9. .................................

10. .......................................... ......................................... 10. .................................

11. .......................................... ....................................... 11. .................................

12. .......................................... .......................................... 12. .................................

13. .......................................... ........................................... 13. .................................

14. .......................................... ........................................... 14. .................................

15. .......................................... ............................................ 15. .................................

 PEMERINTAH KABUPATEN MAGELANG
BADAN PENANAMAN MODAL DAN PELAYANAN
PERIZINAN TERPADU (BPMPPT)

SEDIAN

Kepada Yth : Bapak Asisten Pemerintahan.

Dari : Kepala BPMPPT Kab.Magelang
Nomor : / / 59/2012.
Tanggal : 2 Maret 2012
Sifat : Segera.
Lampiran : 1(satu) Lembar.
Perihal : Rapat penataan menara telekomunikasi ( tower ) atau
BTS di wilayah Kab.Magelang

Catatan 1. Mohon Tanda Tangan ( )

2. Mohon Petunjuk ( )
3. Mohon Koreksi ( )