GAP Portal

COMPLAINT ASSESSMENT FORM

Supplier Name

Cinjoejaya Perkasamuda

Complaint No. :

Address

CIF No.: 011/WEB/III/2026

Phone

PIC

Invoice No. :

PO

Quality Order

Product : HVS ROLL

Quality Complaint

Specification : HVS ROLL 70 88 RAP PREMIUM

Problem :

-FLUI

Kategory of Complaint

Claim value (IDR/USD/SGD/EUR) :
Rp 6.721.150,-

In Words

( Enam juta tujuh ratus dua puluh satu ribu seratus lima puluh rupiah )

Ect ..................................................................................................................................

Data :

Original sample / before process	Copy of DN
Sample after process	Photo
Comparison sample	Packaging
Inspection Card	Pull Tape ( for Picking / Dusting problem )
Ream Label
Ect

Notes :

NOMOR ID ROLL	QTY	KET' RUSAK
3155482117	587 KG	FLUI
NO.DO	SJ26043/01710

Jakarta, 13 Maret 2026

Prepared by,

Checked by,

Approved by,

13-03-2026

( Gita Siti )

13-03-2026

( Maurina Gurning )

( ........................ )

( Staff Pembelian )

( Ka. Bag. Pembelian )

( Supplier )