GAP Portal

COMPLAINT ASSESSMENT FORM

Supplier Name

Cakrawala Mega Indah

Complaint No. :

Address

CIF No.: 018/WEB/X/2026

Phone

PIC

Invoice No. :

PO

Quantity Order

Product : HVS ROLL

Quantity Complaint

Specification : HVS ROLL 70 73 AQNA

Problem :

KERTAS PEYANG /PENYOK

Kategory of Complaint

Claim value (IDR/USD/SGD/EUR) :

In Words

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

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 :

NO.DO	5782472388
ID ROLL   214518175

Jakarta, 03 Oktober 2026

Prepared by,

Checked by,

Approved by,

03-10-2026

( Gita Siti )

03-10-2026

( Maurina Gurning )

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

( Staff Pembelian )

( Ka. Bag. Pembelian )

( Supplier )