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NOMOR SKCK : ..............................

DAFTAR PERTANYAAN
SURAT KETERANGAN CATATAN KEPOLISIAN

NAMA PEMOHON

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

KEPERLUAN

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

Yang bertanda tangan dibawah ini :


The undersigned is :
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

N a m a : .............................................................................................................................
Name
Tempat / tanggal Lahir : ......................................................................................................
Place / Date of Birth
A g a m a : ..........................................................................................................................
Religion
Kebangsaan : .....................................................................................................................
Nationality
Jenis Kelamin : ...................................................................................................................
Male / Female
Kawin / Tidak kawin : ..........................................................................................................
Married / Not Married
Pekerjaan : .........................................................................................................................
Occupation
Alamat sekarang : ...............................................................................................................
Current address
Nomor Kartu Penduduk: .....................................................................................................
Citizen Card Number
Nomor Pasport : ..................................................................................................................
Pasport number
No. KITAS / KITAP : ............................................................................................................
Stay Permint No.
Nomor Telp./ Hp. : ..............................................................................................................
Phone number

Menerangkan hal-hal sebagai jawaban / keterangan atas pertanyaan-pertanyaan diajukan sebagai


berikut :
Explain things as answer / explanation for the questions posed as follows :
I.

Hubungan Kekeluargaan (Relationship) :


1.

Istri / Suami (Wife / Husband)


a.
N a m a : ..........................................................................................................
Name
b.
U m u r : ...........................................................................................................
Age
c.
A g a m a : .......................................................................................................
Religion
d.
Kebangsaan : ...................................................................................................
Nationality
e.
Pekerjaan : .......................................................................................................
Occupation
f.
Alamat : ............................................................................................................
Address

2.

Bapak sendiri (Father)


a.
b.
c.
d.
e.
f.

N a m a : ..........................................................................................................
Name
U m u r : ...........................................................................................................
Age
A g a m a : .......................................................................................................
Religion
Kebangsaan : ...................................................................................................
Nationality
Pekerjaan : .......................................................................................................
Occupation
Alamat : ............................................................................................................
Address

3.

Ibu sendiri (Mother)


a.
b.
c.
d.
e.
f.

4.

N a m a : ..........................................................................................................
Name
U m u r : ...........................................................................................................
Age
A g a m a : .......................................................................................................
Religion
Kebangsaan : ...................................................................................................
Nationality
Pekerjaan : .......................................................................................................
Occupation
Alamat : ............................................................................................................
Address

Saudara Sekandung / Tiri (Siblings) :


Nama (Name)

Umur(Age)

Pekerjaan (Job)

Alamat (Address)

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

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

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

a. ..........................
b. . .........................
c. . .........................
d. . .........................
5.

Riwayat Sekolah (Education History) :


a.
b.
c.
d.

II.

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

Tahun lulus (Year of Graduation) :


Tahun lulus (Year of Graduation) :
Tahun lulus (Year of Graduation) :
Tahun lulus (Year of Graduation) :

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

Tersangkut Perkara Pidana dan Pelanggaran (Criminal Case Lodget and Abuse) :
1.

Perkara Pidana (Criminal Case)


a.
Apakah Saudara pernah tersangkut perkara pidana ? / Have you ever caught
in a criminal case?
.........................................................................................................................
b.
Dalam perkara apa? / in what kind of case?
.........................................................................................................................
c.
Bagaimana putusannya dan Vonis hakim? / What is the decision of the judge
and verdict?
.........................................................................................................................
d.
Apakah Saudara sedang dalam proses perkara pidana? Kasus apa ? / Are you
currently in the process of a criminal case ?What kind of case ?
.........................................................................................................................
e.
Sampai sejauh mana proses hukumnya? / To what extend is the legal process?
.........................................................................................................................

2.

Pelanggaran (Violation)
a.

b.

c.

Apakah Saudara pernah melakukan pelanggaran hukum dan atau normanorma sosial / Have you ever violated the law and social norms or other?
....................................................................................................................
Pelanggaran hukum atau norma-norma sosial apa? What kind of violations of
the law
....................................................................................................................
Sampai sejauh mana prosesnya? / To what extent is the process?
....................................................................................................................

III.

INFORMASI LAIN (OTHER INFORMATION)


1.

2.

3.

IV.

Riwayat pekerjaan / negara-negara yang pernah dikunjungi / work experience and


countries you have ever visited before : (sebutkan tahun berapa, dalam rangka apa
dan negara mana yang dikunjungi)
.............................................................................................................................
.............................................................................................................................
Kesenangan / Kegemaran / Hobi / Pleasure / Fondness/ hobbies :
.............................................................................................................................
.............................................................................................................................
Alamat yang mudah dihubungi (no. telepon) / Contact no. in case of emergency
(phone number):
.............................................................................................................................

Sponsor (khusus orang asing / foreigners)


1.
2.
3.
4.

Disponsori oleh (Sponsored by) : ...............................................................................


Alamat Sponsor (Sponsor address) : .........................................................................
Telp. / Fax. (Tel. / Fax) :.............................................................................................
Jenis Usaha (Type of Bussiness) :.............................................................................

Keterangan diatas saya buat dengan sebenarnya atas sumpah menurut kepercayaan saya, apabila
dikemudian hari ternyata keterangan ini tidak benar maka saya sanggup dituntut berdasarkan
hukum yang berlaku. / I have made the above statement the truth according to my own belief, if in
the near future this informasion turn out to be false then I could be prosecuted under applicable
laws.

........................., ..............................................

( --------------------------------------------- )

KARTU Tik
1.

a. Nama :
b. Alias

2.

Kebangsaan
a. Tgl. No. KTP

PHOTO

b. Tgl. / No. Pasport :


3.

Agama Islam

4.

a. Tgl. Lahir/ Umur


b. Tempat Lahir

5.

Alamat:

6.

Perubahan Alamat :

7.

Kedudukan dalam keluarga :

8.

a. Nama Bapak :
Nama Ibu

b. Alamat :
9.

Pekerjaan:

10.

a. Nama Istri/Suami:

Umur:

11. Sanak/Saudara yang menjadi Tanggungan:

b. Nama Bapak Istri/Suami:


c. Nama Ibu Istri / Suami:

Alamat :

d. Alamat
12.

13.

Anak-anak :

Umur:

Anak-anak :

1.

4.

2.

5.

3.

6.

Umur:

Ciri-Ciri Badan :
1. Rambut :

2. Muka :

4. Tinggi :

5. Tanda Istimewa :

14.

Rumus Sidik Jari :

15.

Riwayat Sekolah

3. Kulit :

Tahun Lulus :

1.
2.
3.
4.
16.

Kesenangan/Kegemaran/Hobi :

17.

Catatan Kriminal yang ada :

Diisi menurut keadaan


Tgl.

Kepala Kepolisian .

18

Data/Keterangan-2 Lain :