GAP Portal

COMPLAINT ASSESSMENT FORM

Supplier Name

Cakrawala Mega Indah

Complaint No. :

Address

CIF No.: 010/WRH/XI/2025

Phone

PIC

Invoice No. :

PO

Quality Order

Product : HVS ROLL

Quality Complaint

Specification : HVS ROLL 58 101 AQNA

Problem :

BERAT TIMBANGAN KURANG TIDAK SESUAI LABEL

Kategory of Complaint

Quality	Handling
Packaging	Quantity
Delivery

Claim value (IDR/USD/SGD/EUR) :
Rp.52.181.500.-

In Words

( Lima puluh dua juta seratus delapan puluh satu ribu lima ratus 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' HASIL TIMBANG
213947527	678.19	HASIL TIMBANG 673.80
213947572	678.19	HASIL TIMBANG 675.40
213947504	678.19	HASIL TIMBANG 668.40
213947476	678.19	HASIL TIMBANG 672.40
213947537	678.19	HASIL TIMBANG 675.20
213947546	678.19	HASIL TIMBANG 671.80
213947547	678.19	HASIL TIMBANG 674.80
213898600	678.19	HASIL TIMBANG 676.40
213947684	678.19	HASIL TIMBANG 670.60
213947707	678.19	HASIL TIMBANG 674
NO. PO	PO/25/0188		NO.DO	5782277281

Jakarta, 26 November 2025

Prepared by,

Checked by,

Approved by,

26-11-2025

( Gita Siti )

26-11-2025

( Maurina Gurning )

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

( Staff Pembelian )

( Ka. Bag. Pembelian )

( Supplier )

PT Gelora Aksara Pratama

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