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    NAMA:.......................................................... NAMA:.......................................................... NAMA:..........................................................

    TETALA / UMUR: .......................................................... TETALA / UMUR: .......................................................... TETALA / UMUR: ..........................................................


    ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ...........................................
    BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm

    NAMA:.......................................................... NAMA:.......................................................... NAMA:..........................................................


    TETALA / UMUR: .......................................................... TETALA / UMUR: .......................................................... TETALA / UMUR: ..........................................................
    ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ...........................................
    BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm

    NAMA:.......................................................... NAMA:.......................................................... NAMA:..........................................................


    TETALA / UMUR: .......................................................... TETALA / UMUR: .......................................................... TETALA / UMUR: ..........................................................
    ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ...........................................
    BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm

    NAMA:.......................................................... NAMA:.......................................................... NAMA:..........................................................


    TETALA / UMUR: .......................................................... TETALA / UMUR: .......................................................... TETALA / UMUR: ..........................................................
    ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ...........................................
    BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm

    NAMA:.......................................................... NAMA:.......................................................... NAMA:..........................................................


    TETALA / UMUR: .......................................................... TETALA / UMUR: .......................................................... TETALA / UMUR: ..........................................................
    ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ...........................................
    BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm

    NAMA:.......................................................... NAMA:.......................................................... NAMA:..........................................................


    TETALA / UMUR: .......................................................... TETALA / UMUR: .......................................................... TETALA / UMUR: ..........................................................
    ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ........................................... ALAMAT: DUSUN ...........................................
    BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm BB / TB: ............... kg / .............. cm

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