03. formulir permohonan informasi publik

PEMERINTAH KABUPATEN REMBANG

SEKRETARIAT PPID
Jl. Gatot Subroto No.8 Telp. (0295) 6980426 Fax. (0295) 6980425 Rembang 59211
http://www.rembangkab.go.id email: ppid@rembangkab.go.id

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

: ________________________________________________________________

Alamat

: ________________________________________________________________
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Nomor Telepon/E-Mail

: ________________________________________________________________

Rincian Informasi yang dibutuhkan : ________________________________________________________________
(tambahkan kertas bila perlu)

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Tujuan Penggunaan Informasi

: ________________________________________________________________
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Cara Memperoleh Informasi**

: 1.
2.

Cara Mendapatkan Salinan Informasi*** : 1.

Melihat/membaca/mendengarkan/mencatat
Mendapatkan salinan informasi (hardcopy/softcopy)***

Mengambil Langsung

2.

Kurir

3.

Pos

4.

Kurir

5.

E-Mail

6.

Faksimili

Rembang, _____________________________
Petugas Pelayanan Informasi

Pemohon Informasi

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