formulir pemohon informasi publik

PEMERINTAH PROVINSI NUSA TENGGARA BARAT

DINAS PERINDUSTRIAN DAN PERDAGANGAN
Jalan Langko Nomor : 61 Telp. (0370) 633646, 633166 Fax. 633736
E-mail: ppidperindagntb@gmail.com / disperindag_ntb@bp3ed.disperindag.ntbprov.go.id

MATARAM
Kode Pos 83125

FORMULIR PERMOHONAN INFORMASI
No. Pendaftaran (diisi petugas)*:................................................
Nama
Alamat

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Nomor Telepon/email
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Rincian Informasi yang
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dibutuhkan
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(tambahkan kertas bila perlu)
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Tujuan Penggunaan Informasi :.....................................................................................................
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Cara memperoleh informasi** :
1
Melihat/membaca/mendengarkan/mencatat

Cara Mendapatkan salinan
Informasi***

2

Mendapatkan salinan informasi (hardcopy/softcopy)

1

Mengambil langsung

2

Kurir

3

Pos

4

Kurir

5

E-mail

6

Fax

:

Mataram,.................................2013
Petugas Pelayanan Informasi
(Penerima permohonan)

Pemohon Informasi

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(nama dan tanda tangan)

(nama dan tanda tangan)

Keterangan:
* Diisi oleh petugas berdasarkan nomor registrasi permohonan Informasi Publik
** Pilih salah satu dengan memberi tanda ( √ )
*** coret yang tidak perlu