Anda di halaman 1dari 1

--------~~

~ ..._
~~'::;.~
.:::;..
-c:. . 1
­

~~ I
K 35150993616 <rl
~I
I
I
~

~-3' . ¥J~ :?-; ~'~ . . .... ::: ._~> z-: <- :-:§f' -~~ -'"~-- : -::- ' ~. -r~-~ .... - : ~:: : - ~~ -- ~ .
_-'" Na_rtia Kepala Keluarga : Dr . SOCTAM RIZKYoW lCAKSONO, S.Kom. M.M. ~ . Kecamatan : KRIAN
,~~~""'., AJamat : : TAl';:113AK ,UTARA 35 " C
_~ ~ .: Kabupa t en{ Ko ta : SIDOARJO
.~ RT/ RW ~:;L __ : 00lf! 001 -
C

~. - ~)
• ..

= Kode Pos : 61262. .r·1


:~ "" I
~' Des a/Kef u r a banJ.~ ;~ : TAMBAKKEMERAKAN ~" Provinsi ; JAWATIlVtUR "I
. ?~ C -;:;:-----~ ~~l en ;~~p- - ~ ; ~- ~l NlK -e- KJ~"I~ r Te~ati~I;l f T~~~aJ - A gam a - ?en dldika~ J ellis Pekerjaan I
c:-~4 ~:~ ~:;: ~ : : ~ 't::: :~: ;:;~: :;~H~~:~ ;:;;~~ :;Y.:: ;: ~: :~ ~ :~:~ ~ ~W::i::~;@~t~:;~:f: ?m~~ :~:~ ~:~ ~:f;:~~:~:,,:r~~{: :~: ~ ~:~i;';~~~~:~<)~{?:::~ : ~:~ ~:~~;: : #f:: :~:};;:~:t~~::~: ~~~ ~:~ ~ : : : ~:f'~~f~;;~~::;U~:~~~~: ~~t~~ ::~ ;:: ;: ;: :~f~::::h:: ::l:tf~~\~:~j~t~%:: : : : :;: ;:{:~~ ~:n:f:ttI;)H:::: :?:~J:: : :;: : ~:;{?t~: ??::: :?: I
B~' 1 Dr.SOETAI.I RlZKvWf~o:s .~LIll . M.M . •-, ~ \'[' 36161 11100760009 L!',KI·LA KI SURA6AYA ~ 11-09-19H i ISL AM STRATA·1lI DOS EN • I
~ .= ANIK W1f)iYA Nt l~.i ~;;:.;:... ;:~ 3515115~$10001 ~
II
2 , PEREMPUAN JEMBER . ' 16·0 8-1981 ISLAM SLT N SElXRAJAT M ENGURUS RUM AH T ANGGA
'~; ~ 3 ° A LFI NURNA61vk sd6 AM RIZi{Y '* 00 •• 3515115101030001 PEREMPUAN SIOOARJO .: 11-0 1- 2003 ISL AM SLT PfSECtRAJAT - PELAJARIMAHAS1SWA

:0.0~ . ~ ~O ~=.A~~;:~STIRA ~15112405120()05 ~AK1-LAi<l ~ALANG '.. _~ "" . 24.05-20 12 ~SLAM ~IDA~i8 LM SEKOLAH ~ELlIMfTlOAK 8EKER~ - t
rrr r:-- - --- _.---_
- :--- -___:__ ~ =-------------- ------=---::---t
. ,:, - - - -;"-, -: I-. .I:, --I:
.~ ~~~~~l~~- -.,p-- - ' - ~ - ~--- ~------------ ~- - - ---· i: --

~ ~§1ir ~ '·C,"
... ':: 1-
-
~
_
· ...:-~' =t. . .~ . L I
- ~- -

~
.''';f- ~~t~~~~t-ii $t~itis ~ub Ungan := Dokumen imigrasl ~ Nama On m g Tu a
I
~
~..:""
NQ. ~%~- ,e " . -='- ~=>'"
!t~L~a~ lla n
'-,= " C.O'
, '% Qat;anl:Keluarga
Kewarganegaraan
~ §" . No. Paspor No. KITAS/KITAP - i Ayah
.
Ibu I
-~ lmLt~xtii!~t}KKH~H:~~f:::tt1.mttgm}c::i~~~:~~:h:JHt\tI~:t~;: ;::~::t~K8:~~Kt~tt;I ~:::ltt~~;~:~.«~tt~:n:t;~:;: }tt?I~:~ttt}}tt:~~~:;::itjf~~:t{{;::;;m;;::~t;{:;;::tKt:t>::;:;:~;;t:~:::t{;:;;::;;;::tttt;::t:t{jt~ft:;;:::;::;::t::::t:~:~t~tt~t~~tKd I
=~k =z:
~i '
1
2
I<AWlN~~'§ ,c
KAwlr,f- ..,-·/ -
V£PAL',{l<ELUARGA ~ WNI '-
iSTRl~% WNl
-
-
.
-
, SOET AM T RI80WO
I NANA;"G3UKAERI ..
R POERIASRI
DWIPUTRI Y

I
.4.=. =3 BELU ~(K AWl ti~ A NA k%C:2 . > WNI - -=-. - SOE1 AM RIZI{Y\"1I CAI< SONO ANII< V.... OIYANTl

~ f-4.. s a UM l<A\"IIN -" :A NAK~< WNl • - >. SOET AM RIZKY W1CAKSOI\I() "'" ANIK \-\mJYANT I

.~ 5 ~-., :~;;: ~~; ,:, .


ow - .. _ ..-- ..

5§ ~- '~_ .=-. -::~~~,-ic~ ' ~-


:~- ~7 -
..... .

.
-
-
I . !.
..- . ' ­
I.
- l
,~
~
~ + ~._---- :~~ ,
=~' .-
~
~
: .~ I~
I. .
:
.
~
~
-." ,;j o e • - • c' • - . 0
J
~#
\-~='
.::;.~-
~ IlOc08-2015]
~
"'" "7

~
[je Dikeluarkan Tanggal
~.
LEMBAR 1. Kepala Keluarga <
KEPALA KELUARGA
II. RT

SOETAM~'
-~
~
... III. DesajKelurahan
~~ ~_;.:;_---C-~_ IV. Kecamatan ­
~a Dr. S.Kom, LlANTO M.Si
M.M.
~~~~ Taride Tan g anj Cap Jem p ol 151992031014
?

-~~i#
~"""'~-~
' '',c= ~ .& ~~--~

-~'"
~-;.-~ s
~. §..

~.:::
-.-"~

Anda mungkin juga menyukai