BIKERS BROTHERHOOD MOTORCYCLE CLUB

indonesia
BROTHERHOOD-LOYAL-RESPECT-HONOR -PRIDE
SK kemenkumham ri Nomor ahu-0004105.ah.01 .07.tahun 2018

NO PENDAFTARAN

MOHON DIISI DENGAN HURUF CETAK diisi oleh admin

D ATA P R I B A D I
NAMA LENGKAP : ...............................................................................................................................
NAMA PANGGILAN : ...............................................................................................................................
TEMPAT/TGL. LAHIR : ...............................................................................................................................
JENIS KELAMIN : PRIA WANITA GOLONGAN DARAH : A B AB O
NIK KTP/SIM : ...............................................................................................................................
ALAMAT : ...............................................................................................................................
...............................................................................................................................
NO. TELP / HP : ...............................................................................................................................
EMAIL : ...............................................................................................................................

D ATA K E A N G G O TA A N
NO ANGGOTA : ( diisi oleh admin )

KEANGGOTAAN : SS DIPONEGORO LIFE MEMBER HONORARY MEMBER

VIRGIN MEMBER PROSPECT MEMBER
CHAPTER : ............................................................CHECKPOINT :.............................................
TERDAFTAR SEJAK : ...............................................................................................................................
JENIS MOTOR : ........................................................... TAHUN : ..................... NO. POL : ................

D ATA P E K E R J A A N
PEKERJAAN : ...............................................................................................................................
JABATAN : ...............................................................................................................................
Seluruh data yang saya isi adalah benar dan dapat dipertanggungjawabkan.
Dengan ini saya menyetujui semua aturan yang berlaku di organisasi bikers BROTHERHOOD MC dan siap
menerima sangsi apabila melanggar dari aturan yang sudah ditetapkan.

Bandung, 2018

PAS PHOTO
UKURAN 4 X 6 CM

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BIKERS BROTHERHOOD MC
JL. Soekarno Hatta No. 187 A (Depan Lapas Banceuy) Karasak Barat-Bandung
Website : www.bikersbrotherhood.id e-mail : admin@bikersbrotherhood.id