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DAFTAR LAYANAN KELOMPOK RENTAN
Formulir Daftar Layanan Kelompok Rentan merupakan formulir permohonan untuk memperoleh informasi dan atau membuat laporan pengaduan kepada BBPOM di Surabaya yang diperuntukkan bagi kelompok rentan (Disabilitas, Ibu Hamil, Ibu Menyusui, Lanjut Usia)
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* Indicates required question
Nama
*
Your answer
Jenis Kelamin
*
Perempuan
Laki-laki
Usia
*
=< 20
21 - 30
31 - 40
40 - 50
51 - 60
>= 61
Jenis Kelompok Rentan
*
Disabilitas
Ibu Hamil
Ibu Menyusui
Lanjut Usia
Alamat
*
Your answer
No Hp/ Whatsapp
*
Your answer
Nama Instansi/ Perusahaan (Jika tidak ada boleh diisi dengan tanda - )
*
Your answer
Perihal Pengaduan
*
Your answer
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