S10R092507 760005 PENCATATAN SIPIL REGISTRY OFFICE WARGA NEGARA . |NDONESIA. NATIONALITY KUTIPAN AKTA KELAHIRAN EXCERPT OF BIRTH CERTIFI Berdasarkan Akta Kelahiran Nomor ‘virtue of menurut stbld in JISETULPANCAR. BUD, ae empl. Jabichaki...swands.istri. clad... Nengab, Sumada, slengan, Made. Mtn, Kutipan ini dikeluarkan e excerpt is al nA SP eunvicn.Bulelens.n.Nomor Induk Kependudukan. Swami» $108092S07760008, Personnel Registration Number’ si $108094906830005 AK 9390061213 PENCATATAN SIPIL REGISTRY OFFICE WARGA NEGARA _!NDONESIA NATIONALITY Se KUTIPAN AKTA PEKKAWINAN EXCERPT OF MARRIAGE CERTIFI. Berdasarkan Akta Perkawinan Nomor ,...,|22/WNI/Tjk/2012 By virtue of Marriage Certificate Number . telah tercatat perkawinan antara, R BUDS :ubilan Desember Katipan ini dikeluarkan fags ieee iy . lima MaretNo. 42. oa ob 0629222 DEPARTEMEN PENDIDIKAN DAN KEBUDAYAAN REPUBLIK INDONESIA SURAT TANDA TAMAT BELAJAR SEKOLAH MENENGAH UMUM TINGKAT PERTAMA (SMP) ‘Yang bertanda, Peer. ini) Kepa eee 4 : menerangkan bahwa: LKETUT_PANCAR BUD! berhasil dalam evaluasi belajar tahap akhir guna memperoleh Surat Tanda Tamat Belajar ‘Sekolah Menengah Umum Tingkat Pertama, yang diselenggarakan berdasarkan Keputusan Kepala igs jilayah Departemen Pendidikan dan Kebudayaan Propinsi ape . tanggal ... (vide Keputusan Direktur Jenderal Pendidikan Dasar dan Micaela 19 Oktober 1990, No. 310/C/Kep/I/1990), schingga yang bersangkutan dinyatakan tamat belajar sekolah menengah umum tingkat pertama, Pemegang Surat Tanda Tamat Belajar ini terakhir tc it sebagai siswa, wasta, tercafat Fe Sekolah Past se Tingkat Pe (2 abuy dengan Nomor Indu.Nese aise) quomera Isexyni9g rereR Yolo UeyQIONP BueK sUOsTYE}® TEXYILES UEyEUNBoUeW ALOE} exe9eS !UeBUEIEpUEYP Ye) m4 VeWNON degwue6ue epueL, Tan aT e ueewsesoy “AL Ueuesnjevesed “ih aul vOUYNTSY VIVES ebuenjoy PIES 1 = vanes [ozoznosr] = re86uey vewreniona a Ts ; z : ie m2 Tare wvowva Ini war = Tana uvonva LD a] a Tone avoNa EDN Ea c OS'S VIGNCD FO 7 Teast z "YOM HONS 5 5 eum van 0 ea REL nian ao ea iy avLDY ON | J0dbed ON ‘eBIeR|OM WILTED ‘BoTbiaT waTIT|CG uueBungni srieis on] _ [or Te 5] Te 5 5 7 7 = “pe Teva won| Tene OTIS eo aN area] eee “rare — or | VOOOREOSCECROTE 5 Tawra srevae wanes Terenas wove re se re rina] error TODS ZOPzSOBDTS + era wapoa woUReTG woes WPL eu ene ee vrvevone |praranae[ 0O0e 799600075 = Tawa] Saar aS aOR NR ‘avatsn wow] arm in 050 ‘aver [renans3a| 0068 DBP S| z owe TSS VO or a 5 se rw] brow | 0008152800005 7 wo wr Gee wo icy wr wr o Be! ueetiowed sur eMpued ewety — | ebgoey ye vest ee tN on nwa TBunold oNaTaING : eowusjedngey, + winner ‘uejeweD0>4 Nuvo svivia uve NYNSOW = ueyemPyesea TONG VON LMLIM I eGreno> eyedon CUIEN bTOO2T20E2L0R0TS * ON vouvniay nluvy |Department of Homeland izenship and I Services cys wie > Oe we op) ey ew i Dd a NEE EE ECA} ICH SIN EASE T1I9 Wee aoe PETITION FOR A NONIMMIGRANT WORKER TECHTPT ATE ORE DATE TETTTON ideatper abt ira MT_RUSHMORE KOA/ PALMER GULCH Marea 3, 2009 © |1 of 2 Mine Notice Type: Approval Notice MI RUSHMORE KOR/PRLMER GULCH Clase: #28 c/o JOSH DAISS / SCOTT KAUBISCH BOX 295 HILL CITY sD 57745 Valid from 03/02/2009 to 10/31/2009 fof stay have been approves fd a2 indicated above. The foreigh ork period authorized. Any change in engl cation etens frou the fling of thon, ee Please contact the TRS with any queseicn ee ‘34 when departing the U.8. The left part ia for hie of(her i ty along {ication at a port of entry oF pee 7 Action on an Approved Application ‘oF pre-flight inspection office of i congulate, port ot ‘he approval of thie visa petition & extension, chonge, or adjustnent of status. ee cate enploymen bout tax ¥AtHhgidings = 2 this GRIEG. thactower portion anould be given to the vorker. te oF She should Heep the Fight part pith hie sr her Form 1-84, A/evblDeparture Record ‘The, 1efe part can be used in applying for the new w fe for anviga, E9r Adaiaaion to the United states, or for an BI sae osce for cen sattcsoners tat oe ofment ve in of stay who Leaves aay other required documentation, when applying $5 vequeat that ve nocity approva: Aeeigugtion svacus ana does not guarantee #2: [Please see the additional information on the back. You will be noi U.S. CITIZENSHIP & IMMIGRATION SVC CALIFORNIA SERVICE CENTER P. 0. BOX 30111 LAGUNA NIGUEL CA 92607-0111 Customer Service Telephone: [Form 1797A (Rev. 09/07/93)N. (800) 375-5283 fied separately about any other cases you filed. MO Detach This Half for Personal Records I Receipt # wac-09-100-51673 1-94# 277119747 18 NAME pupt, 1 kerur P. CLASS #28 VALID FROM 03/02/2009 UNTIL 10/31/2009 PETITIONER: MT RUSEMORE KOA/PALMER GU BOX 295 i i 1 I i i I i i i HILL CITY sp 57745 | i i 277119747 18 Receipt Number wac-09-200-51673 Immigration and Naturalization Service 1-94 Departure Record Petitioner: wr rusumore x BUDE I RETUT (07/25/1976 Se Form 1-797A (Rew. 10/51/05) NPOLR! DAERAH BALI “RESOR BULELENG SEKTOR TEIAKULA AMNTELRAMNTELKAMWNTELKAM vay jalan Sit = 8117 — SURAT CATATAN KEPOLISIAN "POLICE RECORD . sen Nomor : SKCK/YANMAS/477/IX/2017/SAT INTELKAM i ini bahw « This is to certify that ‘ rn x Nama IKETUT PANCAR BUD! Name a Jenis Kelamin “OS LAKI LAKE ~ 7 Sex : 0 Indonesia ‘Nationality ae ees ama x Hindu : : Religion iret % : ih - Ter it :Madenan , 25/07/1976 . r Place and date of birth ’ " ‘Tempat tinagal sekarang : Banjar Dinas ‘Kajanan Desa Madenan. i Curentaddress cones seamettiommnen * " ' Kecamatan Féjakula Kabupaten Buleleng Pekeriaan Ki ‘ re . ‘Occupation Nomor Kartu Tanda Penduduk Citizens card number ITAP* selma ia. di Indonesia a: “Sojak Lah _ during his/her stay in Indonesia from ro sampai dengan -:20 September 2017 _ to “ Keterangan mn TeLea pro see ears cme ‘applicant inte ‘Untuk kepertuan/menuiu* / : MELENGKAP! DOKUMEN PELAUT. For the purpose z ‘Berfaku dari tanagal 20 September 2017 Valid rom enTELXAN a " ‘Sampai dengan 20 Maret 2018 To : = " Dikeluarkan di : Tejakula ee $20 September 2017