Community Complaint Form – Geo Dipa Energi

1. Reporting Date^*

2. Contact Method^*

SMS Phone Email Mail In-person

3. Name^*

4. Gender^*

5. Type of Identification (ID Card/Driver's License/Passport) ^*

6. Identification Number^*

7. Address^*

8. Phone/FAX/Email for Contact^*

9. Affiliation^*

Public/Community LSM Institution Project Worker (including part-time and third parties) Representative on behalf of citizens/community (must attach a power of attorney)

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10. What is the complaint?^*

11. Why did it happen?^*

12. How did it happen?^*

13. Who is involved?^*

14. When did it happen?^*

15. Is it recurring? How many times?^*

16. What do you want to resolve the complaint/suggestion? ^*

17. I, the undersigned, declare that the complaint/suggestion submitted is not currently and will not be taken to legal proceedings.^*

I agree I disagree

18. Reporter's Name & Signature^*

19. Focal Point's Name & Signature^*

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