| PEJABAT PENGELOLA INFORMASI DAN DOKUMENTASIPPIDKABUPATEN BOJONEGORO Sekretariat : Lantai I Gedung Pemkab Bojonegoro Jl. P. Mas Tumapel No. 1 Bojonegoro E-mail : dinkominfo@bojonegorokab.go.id, ppidbojonegoro@gmail.com |
FORM KEBERATAN
(RANGKAP DUA)
PERNYATAAN KEBERATAN ATAS PERMOHONAN INFORMASI
A. INFORMASI PENGAJU KEBERATAN
Nomor Registrasi Keberatan : ............................……………………............................................................
Nomor Permohonan Informasi : .....................................................……….......................................................
Alasan Permohonan Informasi : ………………………......................................................................................
Identitas Pemohon
Nama : ……..................................................................................................................
Alamat : ……………………………………..................................................................
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No Telpon/Email : ..........................................................................................................................
Pekerjaan : .....................…………......................................................................................
Identitas Kuasa Pemohon
Nama : ………………………......................................................................................
Alamat : ………………………......................................................................................
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No Telpon/Email : ………………………......................................................................................
B. ALASAN KEBERATAN
C. KASUS POSISI (tambahkan kertas bila perlu)
(Diisi kronologis singkat pengajuan keberatan) .......................................................................................................................................
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D. HARI/TANGGAL TANGGAPAN ATAS KEBERATAN AKAN DIBERIKAN :
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Demikian keberatan ini saya sampaikan, atas perhatian dan tanggapannya, saya ucapkan terima kasih.
Bojonegoro, ..........................
Petugas Pelayanan Informasi Pengaju Keberatan
(Penerima Keberatan)
( ........................ ) ( ...........................)