Gereja Protestan di Indonesia bagian Barat

Jemaat “Markus”
Jl. Raya Cilandak KKO 52, Pasar Minggu / Jakarta Selatan
Telp/Fax. (021) 7800072

FORMULIR PENDAFTARAN NIKAH

(diisi dengan huruf cetak)

I. MEMPELAI LAKI – LAKI

1. Nama Lengkap : .....................................................................................................
2. Tempat / Tanggal Lahir : .....................................................................................................
3. Tempat / Tanggal Baptis : .....................................................................................................
4. Tempat / Tanggal Sidi : .....................................................................................................
5. Pekerjaan : .....................................................................................................
6. Anggota Gereja : .....................................................................................................
7. Alamat : .....................................................................................................
.....................................................................................................
8. Tentang Orangtua
Nama Ayah : ..................................................................................................................
Agama / Gereja : ..................................................................................................................
Nama Ibu : ..................................................................................................................
Agama / Gereja : ..................................................................................................................
Alamat : ..................................................................................................................
..................................................................................................................

II. MEMPELAI PEREMPUAN

1. Nama Lengkap : .....................................................................................................
2. Tempat / Tanggal Lahir : .....................................................................................................
3. Tempat / Tanggal Baptis : .....................................................................................................
4. Tempat / Tanggal Sidi : .....................................................................................................
5. Pekerjaan : .....................................................................................................
6. Anggota Gereja : .....................................................................................................
7. Alamat : .....................................................................................................
.....................................................................................................
8. Tentang Orangtua
Nama Ayah : ..................................................................................................................
Agama / Gereja : ..................................................................................................................
Nama Ibu : ..................................................................................................................
Agama / Gereja : ..................................................................................................................
Alamat : ..................................................................................................................
..................................................................................................................
 Gereja Protestan di Indonesia bagian Barat
Jemaat “Markus”
Jl. Raya Cilandak KKO 52, Pasar Minggu / Jakarta Selatan
Telp/Fax. (021) 7800072

III. SAKSI – SAKSI

1. Saksi I
a) Nama Lengkap : .....................................................................................................
b) Tempat / Tanggal Lahir : .....................................................................................................
c) Pekerjaan : .....................................................................................................
d) Anggota Sidi Gereja : .....................................................................................................

2. Saksi II
a) Nama Lengkap : .....................................................................................................
b) Tempat / Tanggal Lahir : .....................................................................................................
c) Pekerjaan : .....................................................................................................
d) Anggota Sidi Gereja : .....................................................................................................

IV. PEMBERKATAN NIKAH

1. Hari / Tanggal : ..........................................................................................................
2. Jam : ..........................................................................................................
3. Di Gereja : ..........................................................................................................
4. *Dilayani Oleh : ..........................................................................................................

V. NIKAH CATATAN SIPIL

1. Hari / Tanggal : ..........................................................................................................
2. Jam : ..........................................................................................................
3. Di Gereja : ..........................................................................................................
4. *Dilayani Oleh : ..........................................................................................................

*) Diisi Oleh Ketua Majelis Jemaat

Jakarta,............................................
Mempelai Laki – Laki Mempelai Perempuan

(.......................................................) (.......................................................)

Mengetahui Orangtua / Wali,

Mempelai Laki – Laki Mempelai Perempuan

(.......................................................) (.......................................................)
 Gereja Protestan di Indonesia bagian Barat
Jemaat “Markus”
Jl. Raya Cilandak KKO 52, Pasar Minggu / Jakarta Selatan
Telp/Fax. (021) 7800072

CATATAN

1. Permohonan Pemberkatan Nikah diterima oleh Gembala Jemaat pada :

Hari / Tanggal : ..........................................................................................................
2. Pengumuman I : ..........................................................................................................
3. Pengumuman II : ..........................................................................................................
4. Pengembalaan Nikah
I.
: ..........................................................................................................
II.
: ..........................................................................................................
III.
: ..........................................................................................................
IV. : ..........................................................................................................
5. Pengembalaan Terakhir : .....................................................................................................
6. Lampiran – Lampiran :
a) Fotocopy 2 (dua) lembar :
• Akte Lahir
• Surat Baptis
• Surat Sidi
• KTP
• Surat Keterangan dari Kelurahan, model : N1, N2, N4, PM1
(**Fotocopy untuk Gereja, asli untuk Pencatatan Sipil)
• Surat Keterangan belum menikah (bagi yang belum pernah menikah)
(**Fotocopy untuk Gereja, asli untuk Pencatatan Sipil)

b) Surat Keterangan keanggotaan Gereja dan / atau permohonan bantuan

Pelayanan Pemberkatan Nikah dari Gereja Asal (bagi mereka yang bukan
Anggota Jemaat GPIB “Markus”)
c) Foto berpasangan / berdampingan (ukuran 4 x 6 ) : 6 lembar

Jakarta,............................................

Mengetahui, Diterima,

(.......................................................) (.......................................................)
Koordinator Sektor Ketua Majelis Jemaat