GAP Portal

COMPLAINT ASSESSMENT FORM

Supplier Name

Cakrawala Mega Indah

Complaint No. :

Address

CIF No.: 003/WEB/I/2026

Phone

PIC

Invoice No. :

PO

Quality Order

Product : HVS ROLL

Quality Complaint

Specification : HVS ROLL 70 73 AQNA

Problem :

KERTAS KENDOR

Kategory of Complaint

Claim value (IDR/USD/SGD/EUR) :
Rp. 5.651.100.-

In Words

( Lima Juta enam ratus lima puluh satu ribu seratus 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
214056954	491,400	KERTAS KENDOR
NO.DO	5782307226

Jakarta, 26 Januari 2026

Prepared by,

Checked by,

Approved by,

26-01-2026

( Gita Siti )

26-01-2026

( Maurina Gurning )

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

( Staff Pembelian )

( Ka. Bag. Pembelian )

( Supplier )

PT Gelora Aksara Pratama