RUKUN KEMATIAN MUSLIM (RKM)

“MIFTAHUL HUDA SUMBERAGUNG II”

JL. Gurame VII No 10 RT 05 RW 25 Kelurahan Palangka, Kecamatan Jekan Raya Kota Palangkaraya

FORMULIR PENDAFTARAN

No Registrasi : .....................................................................................................
Nama : .....................................................................................................
Tempat Tanggal Lahir : .....................................................................................................
Alamat : .....................................................................................................
......................................................................................................
No Tlpn/No Hp : .....................................................................................................
Tanggal terdaftar : .....................................................................................................

NAMA
NO Tempat Tanggal Lahir Status
(Anggota yang ditanggung)

Palangkaraya, 20

................................................