Formulir Permohonan Keberatan

PERNYATAAN KEBERATAN ATAS PERMINTAAN INFORMASI PUBLIK

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A. INFORMASI PENGAJUAN KEBERATAN
 Tujuan Penggunaan Informasi    *
Nama Pemohon *
Alamat    *
Pekerjaan   *
Nomor telepon     *
  B. ALASAN PENGAJUAN KEBERATAN    *
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