GAP Portal

COMPLAINT ASSESSMENT FORM

Supplier Name

Cakrawala Mega Indah

Complaint No. :

Address

CIF No.: 004/WEB/II/2026

Phone

PIC

Invoice No. :

PO

Quality Order

Product : HVS ROLL

Quality Complaint

Specification : HVS ROLL 70 73 AQNA

Problem :

-FLUI

Kategory of Complaint

Claim value (IDR/USD/SGD/EUR) :
Rp. 5.628.560.-

In Words

( Lima juta enam ratus dua puluh delapan ribu lima ratus enam 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 :

NO.DO	5782272452
NOMOR ID ROLL	QTY	KET' RUSAK
213903144	489,44	FLUI

Jakarta, 25 Februari 2026

Prepared by,

Checked by,

Approved by,

25-02-2026

( Gita Siti )

25-02-2026

( Maurina Gurning )

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

( Staff Pembelian )

( Ka. Bag. Pembelian )

( Supplier )