Benturan Kepentingan

Identitas Pelapor

Nama Lengkap Pelapor (required)

Email Pelapor (required)

NIP Pelapor (required)

Jabatan Pelapor (required)

Unit Kerja Pelapor (required)

HP Pelapor (required)

Identitas Pihak Terlapor

Nama Pihak Terlapor (required)

NIP Pihak Terlapor (required)

Jabatan Pihak Terlapor (required)

Unit kerja pihak terlapor (required)

Nama Penugasan (required)

Nomor Surat Tugas (required)

Benturan kepentingan tersebut berpotensi terjadi karena (required)

Data dukung / bukti permasalahan (Jika ada)

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