TEGAL, 11 APRIL 2001 ~ DS/ KEL. BONGKOK RT 001 RW 005 KEC. KRAMAT KAB TEGAL Pekerigan - ‘Occupation ‘Nomor Kartu Tanda Penduduk 3328151104010005 CCizens card number ‘Nomor PasporKITASIKITAP* Passpor/KITASKITAP nurnber Bumus sii ian @ Mu 000 Fingerprints Formula 1 21_U 000 h dadakan peneliian hi vat keter i £3 of screening trough the issue hereof by vtue of @. Gatalan Kepoisian yang ada Biisting Police rocord b. Surat keterangan dari Kepala Desa /Lureh Information fom local Authorities —_ tidak rlibatan n. apapun ‘the bearer hereof proves not to be involved in any criminal cases ‘selama ia berada di Indonesia deci: 11 APRIL 2001 aring hisher stay in Indonesia from Seca, 26 AGUSTUS 2021 to ini dberkan berhut This cenfcae s issued af the request to the epplcant eek teeteeiaecsi PERSYARATAN PRALA For the purpose Berlaku dar tangaal eg hours aoe Valid tom ‘Samal dengan 25 FEBRUARI 2022 2 SLAWI 26 AGUSTUS 2021 (EPOLISIAN RESOR TEGAL INTELKAM ‘SATU NRP 76100228