Tracing Request Form - Pmi Kabupaten Tebo [PDF]

Citation preview

FORMULIR PERMOHONAN PENCARIAN (TRACING REQUEST) Nomor Kasus/Case No: ________________



6. Informasi tentang PEMOHON/Information about the ENQUIRER: Nama lengkap (sebagaimana dipakai setempat)/Full name (as expressed locally): ........................................ .....................................................................................................................................................



Nama lengkap ayah/Father' full name: ............................................................................. 1. Informasi tentang ORANG YANG DICARI/ Information about SOUGHT PERSON:



Nama lengkap ibu/Mother' full name: ............................................................................ Tanggal lahir/Date of birth: ......................................................Jenis kelamin/Sex: L/M



Nama lengkap (sebagaimana dipakai setempat/Full name (as expressed locally)): ...................................



P/F



.......................................................................................................................................... Nama sebelum menikah/Maiden name: ............................. Nama julukan/Nickname/alias: .....................



Tempat lahir/Place of birth: ................................................................................. Alamat lengkap si Pemohon/Precise address of the Enquirer: ..........................................................



Nama lengkap ayah/Father' full name: .......................................................................................... Nama lengkap ibu/Mother's full name: .......................................................................................... Tanggal lahir/Date of Birth: ......................................................... Jenis kelamin/Sex: L/F



P/M



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



Tempat lahir/Place of Birth: ...................................................................................................... ....................................................................................................



Kebangsaan/Nationality: ................................ Suku Bangsa/Ethnicity: ..........................................



No. Telepon/Telephone: .................................... No. Handphone/Cell phone: ................................



Bahasa Ibu (bahasa pertama yang dikenal orang ybs.)/Mother tongue: ................................................... Pekerjaan/Occupation: ............................................................................................................



E-mail: ..........................................................................................



Agama/Religion: .................................... Status Perkawinan/Marital Status: ................................... Nama suami/istri dan tanggal lahir/Spouse's name and date of birth: ..................................................... Orang yang dicari adalah/The person to be traced is my: ............................................................saya



Saya setuju bahwa nama saya dan nama orang yang dicari diumumkan di media (mis: radio, internet, surat kabar): I agree that my name and the name(s) of the relative(s) sought for be used in public media (e.g. radio, internet, newspaper): YA/YES TIDAK/NO



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



ID Militer/Military ID: ..............................



Pangkat/Rank: ....................................................



Satuan/Unit: ......................................... Tanggal dan tempat penugasan terakhir/Date and place of last assignment: ....................................... Tanda tangan pemohon/Enquirer's signature: .................................................................................



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



Tempat dan tanggal permohonan/Place and date of inquiry: ...............................................................



Permohonan Pencarian ini dikumpulkan oleh (nama)/Tracing request taken by (Name): .......................... PMI Cabang/PMI Branch: ..........................................................................................................



Markas Pusat Palang Merah Indonesia: Jl. Jend. Gatot Subroto Kav. 96, Jakarta 12790 - Indonesia Telp. +62 21 7992325, Fax. +62 21 7995188., Email: [email protected] website, www.palangmerah.org



2. Kejadian yang menyebabkan terpisah atau hilangnya orang yang bersangkutan Circumstances leading to the separation or disappearance: Tanggal dan isi rinci kabar terakhir/Date and details of last news: .................................................... .........................................................................................................................................



4. Informasi tambahan yang mungkin dapat membantu proses pencarian terhadap orang yang dicari: Additional information that may help the tracing of the sought person: Deskripsi tentang bagaimana cara menemukan rumah orang yang dicari jika alamatnya tidak lengkap, misalnya peta coretan tangan yang menunjukkan objek-objek penting yang bisa dijadikan petunjuk (antara lain: sekolah, jembatan, tempat ibadah, tempat kerja, tempat kediaman sebelumnya). A description of how to find the person/s home if the address is insufficient, for example, a hand drawn map indicating landmarks (schools, bridges, place of worship. Place of workshop; employment; former residence etc.)



......................................................................................................................................... Alamat terakhir yang diketahui/Last known address: ..................................................................... ......................................................................................................................................... ......................................................................................................................................... Kejadian persisnya yang menyebabkan hilangnya kontak Precise circumstances leading to loss of contact: ......................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... 3. Anggota keluarga yang mendampingi/Accompanying family members: Nama lengkap Full name



Tanggal lahir Date of birth



Jenis kelamin L/ P Sex F/M



Hubungan dengan orang yang dicari Relationship to sought person



Markas Pusat Palang Merah Indonesia: Jl. Jend. Gatot Subroto Kav. 96, Jakarta 12790 - Indonesia Telp. +62 21 7992325, Fax. +62 21 7995188., Email: [email protected] website, www.palangmerah.org



5. Orang (orang-orang) yang dapat memberikan informasi lebih lanjut Nama lengkap dan alamat siapa saja yang dapat memberikan informasi mengenai keberadaan sekarang orang yang dicari (antara lain kerabat, tetangga, majikan, rekan kerja, guru, teman, dan lain sebagainya) Full name and addresses of any persons who can provide information of the current whereabouts of the traced person (relatives, neighbours, employers, work colleagues, friends etc.)



Markas Pusat Palang Merah Indonesia: Jl. Jend. Gatot Subroto Kav. 96, Jakarta 12790 - Indonesia Telp. +62 21 7992325, Fax. +62 21 7995188., Email: [email protected] website, www.palangmerah.org



CHECKLIST PENCARIAN (TRACING CHECKLIST) Kembalikan formulir ini, setelah diisi, kepada Koordinator RFL PMI Daerah Return this completed form to the RFL Coordinator in the PMI Chapter Tanggal tanggapan/Response date: _________________ Nomor Kasus/Case Number: __________________



ORANG YANG DICARI DITEMUKAN?/SOUGHT PERSON FOUND?



Ya/Yes o Tidak/No o



PMI Cabang/PMI Branch: ______________________



Relawan/Volunteer: ______________________



Orang Yang Dicari/Sought Person: _______________



Pemohon/Enquirer: ______________________



Kemungkinan sumber-sumber informasi dapat dilihat di bawah. Tandai sumber-sumber informasi yang dapat Anda akses dan kembalikan formulir ini kepada Koordinator RFL PMI Daerah selambat-lambatnya pada tanggal tenggat waktu tanggapan./Possible sources of information are listed below. Please indicate those that you were able to check and return this form to the RFL Coordinator in the PMI Chapter by the response date. ___ Buku Telepon/Telephone Directory ___ Organisasi Profesi/Professional Organizations ___ Registrasi Kendaraan Motor/Pengemudi (Motor vehicle/Driver Registration) ___ Kantor Pos/Post Office ___ Kantor PLN/PAM/Telkom (Public Utilities) ___ Media (Nama n Pemohon tidak disebut) Media (Enquirer not identified) ___ Lurah/Kepala Desa (Head of Village)



___ Kunjungan ke rumah dan tetangga (Home visit and Neighbours) ___ Masjid, Gereja, Kuil, Lainnya (Mosque, Church, Temple, Others) ___ Komisi Pemilu (Daftar Pemilih) (Board of Elections (Voter rolls) ___ Dinas Sosial/Social Department ___ Kantor Pajak/Tax Office ___ Koroner/Rumah Sakit (Coroner/Hospitals) ___ Lainnya (sebutkan)/Other (please specify):



KOMENTAR / CATATAN Petugas Kasus (Case Worker COMMENTS):



Izin Pengungkapan Data Kontak / Release of Contact Information Agreement Saya mengizinkan alamat/nomor telepon saya diberitahukan kepada orang (orang-orang) berikut ini: I give my permission to release my address/telephone number to the following person(s): Nama Pemohon (atau lainnya)/Name of Enquirer (or other): _______________________________________ Nama Orang Yang Dicari/Name of Sought Person: ________________________________________________ Tanda tangan/Signature: ___________________________________ Tanggal/Date: ____________________ _____ Alamat/Address: ____________________________________________________________________________



____________________________________________________________________________________ Telepon/Telephone: _________________________________________________________________________



Markas Pusat Palang Merah Indonesia: Jl. Jend. Gatot Subroto Kav. 96, Jakarta 12790 - Indonesia Telp. +62 21 7992325, Fax. +62 21 7995188., Email: [email protected] website, www.palangmerah.org