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FORMULIR PERMOHONAN INFORMASI PUBLIK
Yang bertanda tangan di bawah ini mengajukan permintaan informasi dari RS Sardjito :
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* Indicates required question
Nama Pemohon Informasi
*
Your answer
NIK Sesuai KTP
*
Your answer
Alamat Pemohon Informasi
*
Your answer
Nomor Telepon/ HP
*
Your answer
Informasi yang dibutuhkan
*
Your answer
Alasan Permintaan Informasi
*
Your answer
Nama Pengguna Informasi
*
Your answer
NIK sesuai KTP
*
Your answer
Alamat Pengguna Informasi
*
Your answer
Nomor Telepon/ HP
*
Your answer
Email
*
Your answer
Alasan Penggunaan Informasi
*
Your answer
Cara Memperoleh Informasi
*
Langsung
Website
Email
Fax
Via POS
Required
Format Bahan Informasi
*
Choose
Tercetak
Terekam/File
Cara Mengirim Bahan Informasi
*
Langsung
Pos
Email
Required
Untitled Data dan informasi yang kami peroleh, kami gunakan sesuai dengan ketentuan perundang-undangan yang berlaku.
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