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: 002 KAB/KOTA 1)
: CIOMAS PROVINSI
: PANJALU Halaman
PEMILIH KARTU KELUARGA TEMPAT TANGGAL L P ALAMAT RT RW DUSUN
1 3 5 6 7 8 10
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NO. URUTNOMOR PEMILIH JENIS KELAMIN ALAMAT/TEMPAT TINGGAL
DAFTAR PEMILIH TETAP
PEMILIHAN GUBERNUR DAN WAKIL GUBERNUR JAWA BARAT
TAHUN 2013
MODEL A3 - KWK.KPU
TPS
DESA/KELUARAHAN 1)
KECAMATAN
: CIAMIS
: JAWA BARAT
: ...
9
KETERANGAN 2)
2
NAMA PEMILIHTEMPAT DAN TANGGAL LAHIR
4
UMUR/USIASTATUS PERKAWINAN (B/S/P)
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Nama Tanda Tangan
1. Ketua ADE LUAY ISKANDAR, S.Ag ..............
2. Anggota SUBHAN FIRDAUS, S.Ag ..............
3. Anggota GUGUH RISNA GUNAWAN, S.Pd ..............
2) = Cacat yang disandang pemilih kalau ada
Catatan:
Status Perkainan:
B = Belum nikah
S = Sudah nikah
............., ...............
Disahkan dalam Rapat Pleno PPS Tanggal ......
PANITIA PEMUNGUTAN SUARA
P = Pernah nikah
Jenis Kelamin:
Lk = Laki-laki
Pr = Perempuan
1) = Coret yang tidak perlu
