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    PEMERINTAH KABUPATEN JEMBER DINAS KEPENDUDUKAN DAN

    PENCATATAN SIPIL
    Jln. Jawa No. 18 Telp. 0331-334496 Fax. 0331-337484 J E M B E R 68121

    FORMULIR PERMOHONAN
    KARTU IDENTITAS ANAK

    Nomor Induk Kependudukan (NIK) : .................................................................................................................

    Nama : .................................................................................................................................
    No. Akta Kelahiran : .................................................................................................................................
    Tempat Tanggal Lahir : .................................................................................................................................
    Golongan Darah : .................................................................................................................................
    Nama Ayah : .................................................................................................................................
    Nama Ibu : .................................................................................................................................
    Alamat : .................................................................................................................................
    .................................................................................................................................
    RT...................... RW.......................
    Kelurahan/Desa : .......................................................................................................
    Kecamatan : ..............................................................................................................

    Jember, ...................................................
    Pemohon/Kepala Keluarga Petugas,

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

    PEMERINTAH KABUPATEN JEMBER DINAS KEPENDUDUKAN DAN


    PENCATATAN SIPIL
    Jln. Jawa No. 18 Telp. 0331-334496 Fax. 0331-337484 J E M B E R 68121

    FORMULIR PERMOHONAN
    KARTU IDENTITAS ANAK

    Nomor Induk Kependudukan (NIK) : .................................................................................................................

    Nama : .................................................................................................................................
    No. Akta Kelahiran : .................................................................................................................................
    Tempat Tanggal Lahir : .................................................................................................................................
    Golongan Darah : .................................................................................................................................
    Nama Ayah : .................................................................................................................................
    Nama Ibu : .................................................................................................................................
    Alamat : .................................................................................................................................
    .................................................................................................................................
    RT...................... RW.......................
    Kelurahan/Desa : .......................................................................................................
    Kecamatan : ..............................................................................................................

    Jember, ...................................................
    Pemohon/Kepala Keluarga Petugas,

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

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