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Pengaduan Online 2020-08-03T18:12:36+07:00

FORMULIR PENERIMAAN LAPORAN

FORM OF CASE COMPLAINT ACCEPTANCE

IDENTITAS PELAPOR/REPORTET's IDENTITY

Nama Depan/First Name
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Nama Belakang
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No. Identitas/Identity Number
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Jenis Kelamin
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Tempat lahir
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Tanggal Lahir
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Alamat /Address
Harap masukkan alamat anda
Kode Pos/Zip Code
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Kota/City
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KONTAK

Telepon/Phone
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Email
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Perkara Yang Dilaporkan :
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Waktu Kejadian :

Tanggal
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Jam
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Tempat Kejadian
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Hubungan Dengan Korban
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Latar Belakang/Motif
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Kewarganegaraan
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Suku Bangsa
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Agama
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Sebutkan agama lainnya
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Pekerjaan
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Berkas Yang Disertakan

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Field is required!
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Unggah/Upload Berkas Yang DIsertakan
Upload your documents...
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Nama Saksi-saksi

Saksi 1.
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Saksi 2.
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Saksi 3.
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Usia (tahun)
-
+
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Usia (tahun)
-
+
Field is required!
Usia (tahun)
-
+
Field is required!

IDENTITAS KORBAN/VICTIM's IDENTITY (1)

Nama Depan/First Name
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No. Identitas/Identity Number
Field is required!
Tempat lahir
Field is required!
Kewarganegaraan/Nationality
Field is required!
Nama Belakang
Field is required!
Jenis Kelamin
Field is required!
Tanggal Lahir
Field is required!
Agama
Field is required!
Nama dan ALamat Sekolah
Field is required!

IDENTITAS KORBAN/VICTIM's IDENTITY (2)

Jika Lebih dari satu
Nama Depan/First Name
Field is required!
No. Identitas/Identity Number
Field is required!
Tempat lahir
Field is required!
Kewarganegaraan/Nationality
Field is required!
Nama Belakang
Field is required!
Jenis Kelamin
Field is required!
Tanggal Lahir
Field is required!
Agama
Field is required!
Nama dan ALamat Sekolah
Field is required!
Lembar Kronologis
Lembar Kronologis
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Informasi Tambahan

Pernyataan Publikasi
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Pilih Salah Satu
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Field is required!
Field is required!

Pilih Jadwal Pengaduan

Tanggal
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Jam
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Note
Kepada bapak / ibu / saudara yang sudah melakukan submit / kirim agar melakukan konfirmasi ke nomor whatsapp : 087771102551
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