Albukhary International University

Proof of Electricity and Water Bills

(A) APPLICANT DETAILS

Applicant Name :
Passport No :
Country :

Fathers’s Details Mother’s Details

Name : Name :
Passport : Passport :
No./Identification No No./Identification No
Nationality : Nationality :
Address : Address :
Occupation : Occupation :
Employer : Employer :
Monthly income : Monthly income :
Currency (In your : Currency (In your country :
country currency) currency)

(B) ELECTRICITY AND WATER BILLS

No Name Amount (IDR)

1 Electricity bills
2 Water bills

(C) VERIFICATION

This document should be verified by accredited individual. Such as village /community head or government
oficials etc.
Signature : _______________________ Date : __________________
Name : _______________________ Official stamp :
Position : _______________________
Address : _______________________

*Please attach together with household’s utility bills (water, electricity,etc)