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FORMULIR LAPORAN PENGADUAN GRATIFIKASI POLTEKKES KEMENKES MEDAN
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IDENTITAS PELAPOR
NAMA LENGKAP
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No KTP (NIK)
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Tempat Lahir
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Tanggal Lahir
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Uraian Instansi
Jabatan/Pangkat/Golongan
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Nama Instansi
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Unit Eselon /II/III/IV/Unit Kerja
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Alamat Email
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Nomor HP
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Alamat Rumah
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Alamat Kantor
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DATA PENERIMAAN GRATIFIKASI
Keterangan Jenis Penerimaan Gratifikasi dan Uraian
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Harga/Nilai Nominal/Taksiran
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Peristiwa Penerimaan
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Tempat Penerimaan Gratifikasi
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Tanggal Penerimaan Gratifikasi
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DATA PEMBERI GRATIFIKASI
Nama Pemberi Gratifikasi
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Pekerjaan dan Jabatan
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Alamat/Telepon/Email
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Hubungan dengan Pemberi
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ALASAN DAN KRONOLOGI
Alasan Pemberian
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Kronologi Penerimaan
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