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No Identitas (KTP/SIM/Pelajar) : .................................................................................. Tempat/Tanggal Lahir : .................................................................................. Golongan Darah : .................................................................................. Jenis Kelamin : .................................................................................. Status Keluarga : .................................................................................. Alamat Rumah : .................................................................................. .................................................................................. .................................................................................. Telepon/HP : .................................................................................. Plat Nomor Kendaraan : .................................................................................. Nomor STNK : .................................................................................. Warna Dasar Motor : ..................................................................................
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