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Form Pemanfaatan Ruang Komunitas
DPMPTSP Kota Palembang / MPP Kota Palembang
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* Indicates required question
Nama Komunitas
*
Your answer
Nama Penanggungjawab
*
Your answer
Nomor Identitas Penanggungjawab
*
(KTP/SIM/PASPOR)
Your answer
Alamat
*
(Alamat sesuai identitas)
Your answer
Nomor Handphone Penanggungjawab
*
(nomor handphone aktif)
Your answer
Nama Contact Person Lainnya
*
Your answer
HP Contact Person
*
(nomor handphone aktif)
Your answer
Pemakaian Ruang
*
Choose
Lantai Dasar
Lantai 1
Lantai Dasar dan Lantai 1
Hari Mulai Pemakaian Ruang
*
Choose
Senin
Selasa
Rabu
Kamis
Jumat
Tanggal Mulai Pemakaian Ruang
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Tanggal Akhir Pemakaian Ruang
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Maksud/Tujuan Pemakaian Ruang
*
Your answer
Jumlah peserta komunitas yang akan hadir
*
Your answer
Peralatan yang akan dibawa
(bila ada)
Your answer
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