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Buku Pedoman Pelayanan Informasi Publik - Media Center ...

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PEMERINTAH KOTA MALANG(NAMA SKPD)Jl. ............... Telp..................M A L A N GKode Pos...........FORMOLIR PENOLAKAN PERMOHONAN INFORMASI PUBLIK(RANGKAP DUA)No. Pendaftaran (diisi petugas)* : .......................................Nama : ..........................................................................................................Alamat : ..............................................................................................................................................................................................................................................................................................................................Nomor Telepon/E-mail : ..............................................................................................................................................................................................................................................................................................................................<strong>Informasi</strong> yang dibutuhkan : ........................................................................................................................................................................................................................................................................................................................................................................................................................................Alasan Pengecualian : ........................................................................................................................................................................................................................................................................................................................................................................................................................................<strong>Informasi</strong> <strong>Publik</strong> ini dikecualikan dengan mempertimbangkan bahwa :Dengan mempertimbangkan berbagai konsekuensi berdasarkan alasan pengecualian di atas, memutuskanbahwa : PERMOHONAN INFORMASI DITOLAK. pemberian <strong>Informasi</strong> hanya dapat dilakukan berdasarkanputusan Komisi <strong>Informasi</strong> dan/atau pengadilan.Malang, [tanggal, bulan dan tahun]Petugas <strong>Pelayanan</strong> <strong>Informasi</strong>,(Penerima Permohonan)Pemohon <strong>Informasi</strong>,(.......................................)(.......................................)Keterangan :* Diisi oleh petugas berdasarkan nomor registrasi permohonan <strong>Informasi</strong> publik** Coret yans tidak oerlu<strong>Pedoman</strong> <strong>Pelayanan</strong> Administrasi <strong>Publik</strong>

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