LPK NASIONAL

PENGADUAN

Nomor : ………./P.dt-AR/LPKNI/……. /2011

I. PENGADU              :                               KONSUMEN/AHLI WARIS/KUASA

   Nama                       :         _________________________________________________________________

   Umur                       :         ________________________________________________________________ 

   Jenis Kelamin        :         _________________________________________________________________

  Alamat                    :         _________________________________________________________________                                                                                                                                                                                                       

                                             _________________________________________________________________                                                                                                                                                                                                                                    

  Kode pos                             ________________________________________________________

 Telepon                 :          _________________________________________________________________

  Bukti Diri                                                              :                               KTP/SIM No.                 ______________________________________________________

                                                                                                                                                                                                                                (Lampirkan Fotocopy)

II. YANG DIADUKAN            :               PELAKU USAHA

   Perusahaan     :           _________________________________________________________________

   Alamat             :           _________________________________________________________________                                                                                                                                                                                                                 

                                         _____________________________________________________________

                                                                                                                                                                                                                                   

   Kode Pos        :           ________________________________________________________

                                                Telepon                                                               :                               _________________________________________________________________

                                                Fax                                                                                                         :                               _________________________________________________________________

III.                           TENTANG PENGADUAN

1.                                     Jenis Pengaduan                              :                             _________________________________________________________

                                                                                                                                                                                                                                           

2.                                     Saat Kejadian                                                     :                               Tanggal                                                 :                             ____________________________________________

                                                                                                                                                                                                                                            Jam/waktu                         :                               ____________________________________________

                                                                                                                                                                                                                                            Tempat/Lokasi  :                               __________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                           

3.                                     Bukti-Bukti                                                                          :                               a.            Bukti Pembelian               :                              ______________________________________

                                                                                                                                                                                                                                            b.            Bukti Saksi                                                                           :                             ______________________________________

                                                                                                                                                                                                                                            c.             Barang Bukti                                       :                               ______________________________________

                                                4.                            Bentuk kerugian yang diderita                   a.            Material               :                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                b.            Phisik                                    :                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ______________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ______________________________________

                               

VI.                          PERNYATAAN KONSUMEN

Demikian form ini saya isi dengan benar dan jujur serta dapat dipertanggung jawabkan sesuai peraturan yang berlaku.

YANG MENGADUKAN – KONSUMEN

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