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UNIT PEMBERANTASAN GRATIFIKASI KABUPATEN PASURUAN
Form Laporan Gratifikasi
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Tanggal Pelaporan
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MM
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DD
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YYYY
NAMA LENGKAP
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NIK / NIP
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TEMPAT LAHIR
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TGL. LAHIR
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DD
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YYYY
EMAIL
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NO. HP
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PANGKAT
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JABATAN
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UNIT KERJA / DEPARTEMEN
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SUB UNIT KERJA
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PROVINSI
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KABUPATEN / KOTA
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ALAMAT RUMAH
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TELP. RUMAH
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JENIS PELAPORAN
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JENIS PERISTIWA
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JENIS PENERIMAAN
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URAIAN BARANG
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MATA UANG
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NILAI NOMINAL / TAFSIRAN
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TEMPAT PENERIMAAN
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TGL. PENERIMAAN
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MM
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DD
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YYYY
NAMA PEMBERI
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PEKERJAAN / JABATAN PEMBERI
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EMAIL PEMBERI
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NO. TLP PEMBERI
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HUBUNGAN DENGAN PEMBERI
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ALASAN PEMBERIAN
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KRONOLOGIS PEMBERIAN
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