PELAKSANAAN DI :.....................................................................................................
TANGGAL . .: .....................................................................................................
JAM :......................................................................................................
MAS KAWIN :......................................................................................................
I. CALON SUAMI :......................................................................................................
1. Nama lengkap dan alias : ......................................................................................................
2. Bin : ......................................................................................................
3. Tempat dan tanggal lahir : ......................................................................................................
4. Warga Negara : ......................................................................................................
5. Agama : ......................................................................................................
6. Pekerjaan : ......................................................................................................
7. Tempat tinggal : ......................................................................................................
8. NIK : ......................................................................................................