Ciomas tps003

: 003 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

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