KEPOLISIAN NEGARA REPUBLIK INDONE$IA

DAERAH JAWABAruIT
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POLICE
Nomor : SKCK I YANMAS t 2375 I Xll I 2A23 / SAT INTELKAhI
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fh,'S ts fo ceftW that :

Narna : DADANG HERI#ANSYAH
Name
Jparsl(elamin,
'' : LAKI{AKI
Sex
Kchanflsaen : lstfloNFstA
NationalW l

Agqn'a
Religion
Tempat:lAn-tgl Lahir,
't(At1{wANG, 05 MEI 1975
Place and date of biilh
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&m ea_Lti n ooal qgha rFng , t\r LElvtEtufi. uvLtuu I DESA BUNIJAYA

Address KEC. CIANJUR

Pekeriaan : GURU
Occupatian
Nonpr Kartu Tanda Pendud#k
Citizens card number
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As of screening

bearer here of

during his/her stay in lndonesra

samp.gi d,engan DESEMBE'R.
to
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Ihis c*rtifrcafe is rssued at the reguesf ta the applimnt

U n tu [< ke perluF n/me,nuju*. : PERSYARA.TAN PEMBERKASAN PPPK

For the purpose
Berlaku dari tanogal :2& DESEII,IBER ?jA?'}
Valid from
Samoai deng,an
;' :28 JUNI 2824
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Pada tanooai : 28 Desember 2.023

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