Form Pengajuan Keberatan Informasi Publik 
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Nama pemohon informasi  *
Nomor KTP/NIK *
Pekerjaan  *
Nama Lembaga/ Instansi /perusahaan 
Alamat pemohon informasi *
Alamat Email
No. Telepon/ Wa *
Rincian informasi  yang *
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