PANITIA PEMILIHAN KECAMATAN

( P P K ) TALUN
PEMILIHAN BUPATI DAN WAKIL BUPATI
BLITAR
TAHUN 2015
Alamat: Jalan Raya Timur Nomor 03 Kecamatan Talun Kabupaten Blitar HP : 085 749 608 280

BERITA ACARA
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DALAM PEMILIHAN BUPATI DAN WAKIL BUPATI BLITAR
TAHUN 2015

Pada

hari

ini

Tanggal
Bulan
Tahun Dua Ribu Lima Belas, bertempat di .

...................................

Telah dilaksanakan ..............................................................................................................

yang dihadiri oleh ......... orang, yaitu dari :
1.

........................................................................
2. ........................................................................
3. ........................................................................
4. ........................................................................
sebagaimana terlampir dalam Daftar Hadir.
Materi yang dibahas dalam musyawarah ini serta yang bertindak sebagai pimpinan
rapat dan narasumber adalah sebagai berikut :
A. Topik Musyawarah

...................................................................................................
...................................................................................................
B. Pimpinan Rapat dan Narasumber
Pemimpin rapat

............................................. dari .............................................

Notulen

...................................................................................................

Narasumber

............................................. dari .............................................

............................................. dari .............................................
............................................. dari .............................................

C. Agenda

: 1.

...............................................................................................
2.

...............................................................................................

3.

...............................................................................................
4.

...............................................................................................
5.

...............................................................................................

D. Hasil Rapat sebagai berikut :

1. .......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
2. .......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
3. .......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
4. .......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
5. .......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

E. Rekapitulasi Masukan

1. .......................................................................................................................................
.......................................................................................................................................
2. .......................................................................................................................................
.......................................................................................................................................
3. .......................................................................................................................................
.......................................................................................................................................
Demikian berita acara ini dibuat dan disahkan dengan penuh tanggung jawab agar
dapat digunakan sebagaimana mestinya.
Blitar,

........, ..................... 2015

Mengetahui dan Menyetujui Wakil dari Peserta Musyawarah,

NAMA

UNSUR

TTD

1.
2.
3.
4.
5.

PIMPINAN RAPAT

NOTULEN

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

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