en
id
ClearMIND Report
Required *
GRATIFICATION RECIPIENT DATA
Full Name *
ID No. *
Place of birth *
Date of birth *
NIP (employee index number)
Title
Position *
Division
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Unit *
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Office Address
Province *
DKI JAKARTA
Regency/Mayoralty of Office
KOTA ADM. JAKARTA SELATAN
Office Phone Number *
Home address *
Home province *
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Home Regency/mayoralty
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Home telephone
Mobile telephone *
Other contacts
Other contact number
Email address *
Correspondence address *
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Rumah
Kantor
Type of report *
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Penolakan
Penerimaan
DATA OF GRATIFICATION GIVER
Sequence number
Name *
Organization Gratification Giver *
Address Gratification Giver *
Relations with giver *
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Description of other relations
Reason for giving
DATA RECIPIENTS/REJECTORS OF GRATIFICATION
Incident *
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Pemberian dalam rangka pisah/sambut/mutasi jabatan/ulang tahun
Pemberian terkait dalam pelaksanaan Tugas Pokok Fungsi (Tupoksi)
Pemberian tidak terkait dalam pelaksanaan Tugas Pokok Fungsi (Tupoksi)
Pemberian terkait dengan pernikahan/upacara adat/agama lainnya/musibah/bencana
Keuntungan investasi/manfaat dari koperasi/hadiah undian atau langsung
Lainnya
Description of other types of incidents
Location of gratification object *
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Type of gratification object *
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Description of other items
Description of ticket/accommodation/other facilities
Description of money/other exchange items
Description of gratification object type *
Currency *
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Nominal value/estimation *
Equivalent value in Rupiah *
Date of gratification acceptance/rejection *
Date of report to UPG *
Chronology of gratification acceptance/rejection *
Location of gratification acceptance/rejection *
Willing to hand over money as compensation for gratification items *
Yes
No