GAP Portal

COMPLAINT ASSESSMENT FORM

Supplier Name

Cakrawala Mega Indah

Complaint No. :

Address

CIF No.: 002/WRH/X/2026

Phone

PIC

Invoice No. :

PO

Quantity Order

Product : HVS ROLL

Quantity Complaint

Specification : HVS ROLL 60 73 PINDO ETERNA

Problem :

SELISIH HASIL TIMBANG 1385,85 KG

Kategory of Complaint

Claim value (IDR/USD/SGD/EUR) :
Rp. 16,214,445

In Words

( Enam belas juta dua ratus empat belas ribu empat ratus empat puluh lima 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 :

P2ED050075	479,15	HASIL TIMBANG 459
P2ED049986	479,15	HASIL TIMBANG 460
P2ED050191	479,15	HASIL TIMBANG 463

Jakarta, 10 Oktober 2026

Prepared by,

Checked by,

Approved by,

10-10-2026

( Gita Siti )

10-10-2026

( Maurina Gurning )

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

( Staff Pembelian )

( Ka. Bag. Pembelian )

( Supplier )