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  • Panitia Pengawas Pemilihan Umum: Kecamatan Lakbok Kabupaten Ciamis

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    Imunk Malik Az-Zikri
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    This document is a report from an election monitoring committee in Lakbok Subdistrict, Ciamis Regency detailing their election monitoring activities. It includes sections for the monitor's identification details, a description of three monitoring activities conducted including their purpose and timing, any findings of potential violations including witness and evidence details, and a brief summary of the monitoring results.

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    Blanko_Form_A[1]

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    This document is a report from an election monitoring committee in Lakbok Subdistrict, Ciamis Regency detailing their election monitoring activities. It includes sections for the monitor's identification details, a description of three monitoring activities conducted including their purpose and timing, any findings of potential violations including witness and evidence details, and a brief summary of the monitoring results.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    17 views2 pages

    Panitia Pengawas Pemilihan Umum: Kecamatan Lakbok Kabupaten Ciamis

    Uploaded by

    Imunk Malik Az-Zikri
    This document is a report from an election monitoring committee in Lakbok Subdistrict, Ciamis Regency detailing their election monitoring activities. It includes sections for the monitor's identification details, a description of three monitoring activities conducted including their purpose and timing, any findings of potential violations including witness and evidence details, and a brief summary of the monitoring results.

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    © All Rights Reserved
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    of 2

    FORM A

    PANITIA PENGAWAS PEMILIHAN UMUM


    KECAMATAN LAKBOK KABUPATEN CIAMIS
    Jl. Raya Lakbok No. 732 Kalapasawit - Lakbok Kode Pos : 46385
    Email: panwaslulakbok@gmail.com

    LAPORAN HASIL PENGAWASAN PEMILU


    _______________________________________________________________
    I. Data Pengawas :
    Nama : …………………………………..
    Tempat/Tgl Lahir : …………………………………..
    Jenis Kelamin : …………………………………..
    Jabatan : …………………………………..
    Alamat : …………………………………..
    No. Tlp/Hp : …………………………………..
    E-mail : …………………………………..

    II. Menerangkan telah melakukan kegiatan Pengawasan yaitu:


    1. Kegiatan I
    a. Bentuk : …………………………………..
    b. Tujuan : …………………………………..

    c. Sasaran : …………………………………..

    d. Waktu Dan Tempat : …………………………………..

    2. Kegiatan II
    a. Bentuk : …………………………………..
    b. Tujuan : …………………………………..
    c. Sasaran : …………………………………..
    d. Waktu Dan Tempat : …………………………………..

    3. Kegiatan III
    a. Bentuk : …………………………………..
    b. Tujuan : …………………………………..
    c. Sasaran : …………………………………..
    d. Waktu Dan Tempat : …………………………………..

    III. Mendapatkan Temuan (Jika ditemukan ada dugaan Pelanggaran) :


    1. Peristiwa yang ditemukan
    a. Peristiwa : …………………………………..
    b. Tempat Kejadian : …………………………………..
    c. Waktu Kejadian : …………………………………..
    d. Siapa: 1) Pelaku : …………………………………..
    1
    2) Korban : …………………………………..
    e. Alamat Pelaku : …………………………………..
    2. Saksi – saksi
    1. Nama : .....................................................................
    Alamat : .....................................................................
    2. Nama : .....................................................................
    Alamat : .....................................................................
    3. Nama : .....................................................................
    Alamat : .....................................................................
    3. Bukti-Bukti :
    a.
    b.
    c.
    d.

    4. Uraian singkat Hasil Pengawasan :

    ……………….., …………………. 2018


    Pelaksana Tugas,

    ………………………....

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