Form Pengajuan Surat Keterangan Domisili

Nomor Induk KTP (NIK)

Nama

Tempat Lahir

Tanggal Lahir

Jenis Kelamin Laki - Laki Perempuan

Agama Islam Kristen Hindu Budha Konghucu Katholik

Status Perkawinan Belum Menikah Menikah Duda Janda Cerai Mati Cerai Hidup

Warga Negara --Warga Negara-- Aruba Afghanistan Angola Anguilla Åland Albania Andorra United Arab Emirates Argentina Armenia American Samoa Antarctica French Southern Territories Antigua and Barbuda Australia Austria Azerbaijan Burundi Belgium Benin Bonaire Burkina Faso Bangladesh Bulgaria Bahrain Bahamas Bosnia and Herzegovina Saint Barthélemy Belarus Belize Bermuda Bolivia Brazil Barbados Brunei Bhutan Bouvet Island Botswana Central African Republic Canada Cocos [Keeling] Islands Switzerland Chile China Ivory Coast Cameroon Democratic Republic of the Congo Republic of the Congo Cook Islands Colombia Comoros Cape Verde Costa Rica Cuba Curacao Christmas Island Cayman Islands Cyprus Czech Republic Germany Djibouti Dominica Denmark Dominican Republic Algeria Ecuador Egypt Eritrea Western Sahara Spain Estonia Ethiopia Finland Fiji Falkland Islands France Faroe Islands Micronesia Gabon United Kingdom Georgia Guernsey Ghana Gibraltar Guinea Guadeloupe Gambia Guinea-Bissau Equatorial Guinea Greece Grenada Greenland Guatemala French Guiana Guam Guyana Hong Kong Heard Island and McDonald Islands Honduras Croatia Haiti Hungary Indonesia Isle of Man India British Indian Ocean Territory Ireland Iran Iraq Iceland Israel Italy Jamaica Jersey Jordan Japan Kazakhstan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis South Korea Kuwait Laos Lebanon Liberia Libya Saint Lucia Liechtenstein Sri Lanka Lesotho Lithuania Luxembourg Latvia Macao Saint Martin Morocco Monaco Moldova Madagascar Maldives Mexico Marshall Islands Macedonia Mali Malta Myanmar [Burma] Montenegro Mongolia Northern Mariana Islands Mozambique Mauritania Montserrat Martinique Mauritius Malawi Malaysia Mayotte Namibia New Caledonia Niger Norfolk Island Nigeria Nicaragua Niue Netherlands Norway Nepal Nauru New Zealand Oman Pakistan Panama Pitcairn Islands Peru Philippines Palau Papua New Guinea Poland Puerto Rico North Korea Portugal Paraguay Palestine French Polynesia Qatar Réunion Romania Russia Rwanda Saudi Arabia Sudan Senegal Singapore South Georgia and the South Sandwich Islands Saint Helena Svalbard and Jan Mayen Solomon Islands Sierra Leone El Salvador San Marino Somalia Saint Pierre and Miquelon Serbia South Sudan São Tomé and Príncipe Suriname Slovakia Slovenia Sweden Swaziland Sint Maarten Seychelles Syria Turks and Caicos Islands Chad Togo Thailand Tajikistan Tokelau Turkmenistan East Timor Tonga Trinidad and Tobago Tunisia Turkey Tuvalu Taiwan Tanzania Uganda Ukraine U.S. Minor Outlying Islands Uruguay United States Uzbekistan Vatican City Saint Vincent and the Grenadines Venezuela British Virgin Islands U.S. Virgin Islands Vietnam Vanuatu Wallis and Futuna Samoa Kosovo Yemen South Africa Zambia Zimbabwe

Pekerjaan

Nomor Telpon

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