Nomor: 1B
2. Nama : ___________________________________
Umur : ___________________________________
Pekerjaan : ___________________________________
Alamat : ___________________________________
Menyetujui,
_________________ _________________
Disaksikan oleh,
Saksi-saksi :
1. ________________________ ___________________________________
2. ________________________ ___________________________________
3. ________________________ ___________________________________
4. ________________________ ___________________________________