ClearMIND Report

    Required *
    GRATIFICATION RECIPIENT DATA
    Full Name *
    ID No. *
    Place of birth *
    Date of birth *
    NIP (employee index number)
    Title
    Position *
    Division

    Unit *

    Office Address
    Province *
    Regency/Mayoralty of Office
    Office Phone Number *
    Home address *
    Home province *

    Home Regency/mayoralty
    Home telephone
    Mobile telephone *
    Other contacts
    Other contact number
    Email address *
    Correspondence address *
    Type of report *
    DATA OF GRATIFICATION GIVER
    Sequence number
    Name *
    Organization Gratification Giver *
    Address Gratification Giver *
    Relations with giver *
    Description of other relations
    Reason for giving
    DATA RECIPIENTS/REJECTORS OF GRATIFICATION
    Incident *
    Description of other types of incidents
    Location of gratification object *
    Type of gratification object *
    Description of other items

    Description of ticket/accommodation/other facilities

    Description of money/other exchange items

    Description of gratification object type *

    Currency *

    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 *