KELURAHAN ............................................
KECAMATAN PONTIANAK KOTA
Alamat Sekretariat : Jl. ................................................
SURAT KETERANGAN
Nomor : ....................................................
Pengurus Ketua RT 04 / RW IX, Kelurahan Sungai Bangkong, Kecamatan Pontianak Kota, menerangkan
bahwa :
1. Nama Lengkap : .........................................................................................
2. NIK : .........................................................................................
3. Tempat / Tanggal Lahir : .........................................................................................
4. Jenis Kelamin : .........................................................................................
5. Agama : .........................................................................................
6. Pekerjaan : .........................................................................................
7. Status Perkawinan : .........................................................................................
8. Alamat : .........................................................................................
Nomor Telepon ........................... / HP. ..............................
9. Keterangan lain-lain : .........................................................................................
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