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<html> <head> <title>Dokumen Biodata Sementara</title> </head> <body style="font-family:Arial; font-size:12px"> <table width="749" border="0" cellspacing="0" cellpadding="0" align="center" style="font-family:Arial, Helvetica, sans-serif; font-size:24px"> <tr align="center"> <td><img src="C:\SiakApp\web/images/garuda.jpg" height="143" width="143"></td> </tr> <tr align="center"> <td><strong><u>BIODATA PENDUDUK WARGA NEGARA INDONESIA</u></strong></td> </tr> <tr align="center"> <td><strong>NIK : 7172050908750001</strong></td> </tr> <tr align="center"> <td> </td> </tr> </table> <table width="749" border="0" cellspacing="1" cellpadding="4" align="center"> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td colspan="2"><strong>DATA PERSONAL </strong></td> <td width="10"> </td> <td width="355"> </td> <td width="129" rowspan="5"> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td width="18" align="right">1</td> <td width="232">Nama Lengkap</td> <td align="center"><strong>:</strong></td> <td><b>SAMIDIN</b></td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">2</td> <td>Tempat Lahir</td> <td align="center"><strong>:</strong></td> <td>MAGETAN</td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">3</td> <td>Tanggal Lahir</td> <td align="center"><strong>:</strong></td> <td>09-08-1975</td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right" valign="top">4</td> <td valign="top">Jenis Kelamin</td> <td align="center"><strong>:</strong></td> <td>LAKI-LAKI</td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">5</td> <td>Golongan Darah</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">6</td> <td>Agama</td> <td align="center"><strong>:</strong></td> <td>ISLAM</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">7</td> <td>Pendidikan Terakhir</td> <td align="center"><strong>:</strong></td> <td>SLTA/SEDERAJAT</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">8</td> <td>Jenis Pekerjaan</td> <td align="center"><strong>:</strong></td> <td>KARYAWAN SWASTA</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">9</td> <td>Penyandang Cacat</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">10</td> <td>Status Perkawinan</td> <td align="center"><strong>:</strong></td> <td>KAWIN</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">11</td> <td>Status Hubungan Dalam Keluarga</td> <td align="center"><strong>:</strong></td> <td>KEPALA KELUARGA</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">12</td> <td>NIK Ibu</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">13</td> <td>Nama Lengkap Ibu</td> <td align="center"><strong>:</strong></td> <td>RIYEM</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">14</td> <td>NIK Ayah</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">15</td> <td>Nama Lengkap Ayah</td> <td align="center"><strong>:</strong></td> <td>SUBARI</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">16</td> <td>Alamat Sebelumnya</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:15px"> <td align="right" valign="top">17</td> <td valign="top">Alamat Sekarang</td> <td align="center" valign="top"><strong>:</strong></td> <td>RT. 008 RW. 003 <br>KEL. KELUBIR <br>KEC. TANJUNG PALAS UTARA <br>KAB. BULUNGAN <br>KALIMANTAN UTARA</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td colspan="2"><strong>DATA KEPEMILIKAN DOKUMEN </strong></td> <td><div align="center"></td> <td> </td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">18</td> <td>Nomor Kartu Keluarga (KK)</td> <td align="center"><strong>:</strong></td> <td>7172050707090005</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">19</td> <td>Nomor Passport</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">20</td> <td>Tanggal Berakhir Passport</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">21</td> <td>No. Akta/Surat Kenal Lahir</td> <td align="center"><strong>:</strong></td> <td>14060/D/1988</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">22</td> <td>No. Akta Perkawinan/Buku Nikah</td> <td align="center"><strong>:</strong></td> <td>58/35/V/2003</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">23</td> <td>Tanggal Perkawinan</td> <td align="center"><strong>:</strong></td> <td>16-02-2003</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">24</td> <td>No. Akta Perceraian/Surat Cerai</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> <tr style="font-family:Arial;font-size:12px; line-height:8px"> <td align="right">25</td> <td>Tanggal Perceraian</td> <td align="center"><strong>:</strong></td> <td>-</td> <td> </td> </tr> </table> <table width="749" border="0" cellspacing="0" cellpadding="0" align="center"> <tr> <td height="40"></td> </tr> <tr> <td width="291"></td> <td width="191"></td> <td width="267" align="center"> BULUNGAN, 18-01-2016 </td> </tr> <tr align="center" style="font-family:Arial;font-size:12px; line-height:12px"> <td valign="top" height="80">Yang Bersangkutan,</td> <td width="191"></td> <td valign="top"> PLT. KEPALA DINAS KEPENDUDUKAN DAN PENCATATAN SIPIL </td> </tr> <tr align="center"> <td valign="top"><strong><u>SAMIDIN</u></strong></td> <td width="191"></td> <td><strong><u>EDY JUMANI, B.Ac</u></strong><br> <strong>195809121991031005</strong></td> </tr> </table> </body> </html>
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