Kementerian Perhubungan
Badan Pengembangan Sumber Daya Manusia Perhubungan
Politeknik Keselamatan Transportasi Jalan
Jl. Perintis Kemerdekaan No. 17, Kota Tegal | Telp: (0283) 351061 | Email: pktj@pktj.ac.id
Formulir Permohonan Informasi Publik
No. Pendaftaran (diisi petugas): .............................................
| 1. | Nama Lengkap Pemohon | : | .................................................................................................... |
| 2. | Alamat Lengkap | : | .................................................................................................... |
| 3. | Nomor Identitas (NIK/KTP) | : | .................................................................................................... |
| 4. | Nomor Telepon / WhatsApp | : | .................................................................................................... |
| 5. | Alamat Email | : | .................................................................................................... |
| 6. | Rincian Informasi Yang Dibutuhkan | : | |
| 7. | Tujuan Penggunaan Informasi | : | .................................................................................................... |
| 8. | Cara Memperoleh Informasi | : |
[ ] Melihat/Membaca
[ ] Mendapatkan Salinan (Softcopy)
[ ] Mendapatkan Salinan (Hardcopy)
|
| 9. | Cara Mendapatkan Salinan | : |
[ ] Mengambil Langsung
[ ] Melalui Email
[ ] Jasa Kurir/Pos
|
Petugas PPID PKTJ,
( ..................................................... )
Tegal, ............................................ 20...
Pemohon Informasi,
( ..................................................... )