DKI JAKARTA PROVINCE
JAKARTA CITY
SERIAL REGISTER NAME :
Name
:City/ Date of Birth :
Sex : Female
Address :
RT/RW :
SubDistrict :
Country :
Regency
:
Religion
:
Christian
Marital Status : UnmarriedOccupation : Student
Expiry : 21st of December2016
Nationality : Indonesian Head of SubDistrict/Head of Village
Signature/Fingerprint
Name : Retta Natalia Sinambela
Class : 4Sa01
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