1. Nama : ...............................................................................................
4. Alamat : ..........................................................................................
6. Agama : .................................................................................................
7. Latihan/Rayon : ..................................................................................................
b. Alamat : ...............................................................................................
8. Ranting : .................................................................................................
c. Alamat : ..............................................................................................
Rempung,.....................................
Ketua Perasaudaraan “Setia Hati Terate”
Ranting Pringgasela,
ZAINURI
NIW : 2011 174 0032