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RUMAH ASPIRASI

ANWAR IDRIS
Jln. Medan-Banda Aceh Gampong Matang Sagoe Kecamatan Peusangan

DATA CALON PENERIMA BANTUAN PASANG BARU LISTRIK GRATIS

Nama Lengkap : ...................................................................................

NIK : ...................................................................................

Tempat/Tgl Lahir : ...................................................................................

Jenis Kelamin : ...................................................................................

Pekerjaan : ...................................................................................

Desa/Kelurahan : ............................. ......................................................

Kecamatan : ...................................................................................

Kabupaten/Kota : ...................................................................................

Provinsi : ...................................................................................

Hormat saya,

( ……………………………….. )

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