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................................................................................................................................................................................................................................ ศูนย์สื่อสารสภาขับเคลื่อนการปฏิรูปประเทศ

ตู้ ปณ.๙๙๙ ปณฝ.รัฐสภา กรุงเทพฯ ๑๐๓๐๕ , โทร./โทรสาร ๐ ๒๒๔๔ ๑๘๘๑ , CALL CENTER ๑๗๔๓ , e-mail : [email protected] Webpage : http://www.parliament.go.th/thainrsa58 , FB : ศูนย์สื่อสารสภาขับเคลื่อนการปฏิรูปประเทศ , LINE ID : thainrsa58 ,

สถานีวทิยุกระจายเสียงรฐัสภา , สถานีโทรทัศนร์ัฐสภา , เสนอผ่าน...ศนูย์บริการประชาชน ส านกังานปลัดส านกันายกรฐัมนตรี

ส าหรับเจ้าหน้าที่ เลขท่ีรับ…………………………………. วันเดือนปี..................................... เวลา............................................. ผู้รับเรื่อง......................................

แบบฟอร์มเสนอความคิดเห็นของประชาชนเกี่ยวกับการจัดท าร่างรัฐธรรมนูญและการขับเคลื่อนการปฏิรูปประเทศ

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วันที่............ เดือน...................................... พ.ศ. ..................

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ข้าพเจ้า ค าน าหน้าชื่อ นาย นาง นางสาว อ่ืน ๆ (โปรดระบุ) ………………………………

ชื่อ...............................................นามสกุล ...................................................... เลขประจ าตัวประชาชน....................................

อาชีพ ..........................................................ที่อยู่ที่ติดต่อได้ เลขท่ี ............. หมู่ที่ ........ หมู่บ้าน .............................................

ถนน .................................................แขวง/ต าบล ...................................................... เขต/อ าเภอ............................................

จังหวัด.................................. รหัสไปรษณีย์ ........................ โทร. ........................................ e-mail : …………….…………………

ขอเสนอความคิดเห็นดังนี้.........................

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เอกสารประกอบ .................................................................................................................. ..........................

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ลงชื่อ……………………………………………………………..ผู้เสนอ/ผู้แทน

(…………………………………………………..……….)

................................................................................................................................................................................................................................ ศูนย์สื่อสารสภาขับเคลื่อนการปฏิรูปประเทศ

ตู้ ปณ.๙๙๙ ปณฝ.รัฐสภา กรุงเทพฯ ๑๐๓๐๕ , โทร./โทรสาร ๐ ๒๒๔๔ ๑๘๘๑ , CALL CENTER ๑๗๔๓ , e-mail : [email protected] Webpage : http://www.parliament.go.th/thainrsa58 , FB : ศูนย์สื่อสารสภาขับเคลื่อนการปฏิรูปประเทศ , LINE ID : thainrsa58 ,

สถานีวทิยุกระจายเสียงรฐัสภา , สถานีโทรทัศนร์ัฐสภา , เสนอผ่าน...ศนูย์บริการประชาชน ส านกังานปลัดส านกันายกรฐัมนตรี

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~n';itJtJ ';i~bVII!1~ Cliil ~t1tJ · ศูนย์สื่อสารสภาขับเคลื่อนการปฏิรูปประเทศ ตู้ ปณ.๙๙๙