2
WARGA NEGARA INDONESIA
NIK :
Nama Lengkap : ...................................................................................................................
Tempat Lahir : ........................................................................ Tanggal Lahir : - -
Jenis Kelamin : Laki-Laki Perempuan Golongan Darah : ............
Alamat : .................................................................................................................... RT : ...... RW : .....
Agama : .................................................................. Status Kawin : ................................................
Pekerjaan : .......................................................................................
Mengetahui,
Kepala UPT Dinas Dukcapil Kepala Desa/Lurah
Kec. .........................
............................................. .............................................
NIP. NIP.
NIK :
Nama Lengkap : ...................................................................................................................
Tempat Lahir : ........................................................................ Tanggal Lahir : - -
Jenis Kelamin : Laki-Laki Perempuan Golongan Darah : ............
Alamat : .................................................................................................................... RT : ...... RW : .....
Agama : .................................................................. Status Kawin : ................................................
Pekerjaan : .......................................................................................
Mengetahui,
Kepala UPT Dinas Dukcapil Kepala Desa/Lurah
Kec. .........................
............................................. .............................................
NIP. NIP.