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FORMULIR USULAN JKN KIS
Formulir pengajuan JKN _KIS
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* Indicates required question
No Kartu Keluarga
*
Your answer
No Indu Kependudukan (NIK)
*
Your answer
Nama
*
Your answer
Status
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Suami
Istri
Anak
Lainnya
Tempat Lahir
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Your answer
Tanggal Lahir
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MM
/
DD
/
YYYY
Jenis Kelamin
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1 Laki-Laki
2 Perempuan
Statatus Perkawinan
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Choose
1 Belum Kawin
2 Kawin
3 Cerai
Alamat Tempat Tinggal
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Your answer
RT
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Your answer
RW
*
Your answer
Kode Pos
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Your answer
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