To

The Chief Of Civil

Registry Office

Badung Municipality

I, (The Undersigned) born at on

,
Religion . Occupation . Permanent address
. Previously married: . Son of
address
And address

Together with
born at on
Religion: . Occupation: . Permanent address:
. Previously married: .Daughter of
address and
address
Here with report to the Chief of the Civil Registry Office Badung Municipality. That we intend to
marry and request that information be registered and announced accordingly.

Denpasar, 20 August 2015

(
)

(
)
Solemnization on -

Date : 20 August 2015

Day : Thursday Time : 10.00

NO QUESTION ANSWER

II. GROOM TO BE
1. Name :
2. Nationality :
3. Place and date of Birth :
4. Religion :
5. Occupation :
6. Present address :
7. Previous :
8. Marital status :
9. Ex Wife Name :

II. FATHER OF THE GROOM TO BE

1. Name :
2. Age :
3. Religion :
4. Occupation :
5. Address :

III. MOTHER OF THE GROOM TO BE

1. Name :
2. Age :
3. Religion :
4. Occupation :
5. Address :

IV. BRIDE TO BE
1. Name :
2. Nationality :
3. Place and date of birth :
4. Religion :
5. Occupation :
6. Present address :
7. Previous :
8. Marital Status :
9. Ex. Husbans name :

V. FATHER OF THE BRIDE TO BE

1. Name :
2. Age :
3. Religion :
4. Occupation :
5. Address :
VI. MOTHER OF BRIDE TO BE
1. Name :
2. Age :
3. Religion :
4. Occupation :
5. Address :

VII. FIRST WITNESS

1. Name :
2. Age :
3. Religion :
4. Occupation :
5. Address :

VIII. SECOND WITNESS

1. Name :
2. Age :
3. Religion :
4. Occupation :
5. Address :

Denpasar, 28 December 2014

( )

( )

Signature of witnesses:

I Name of witness 1.

II Name of witness 2.