PROVINCE OF [name]
[name]
National Identity Number: [number]
Name
: [name]
Place/Date of Birth
: [place], dd-mm-yyyy
Gender
: FEMALE
Address
: [address]
RT/RW
: xxx / xxx
Village
: [name]
[name]
Sub-district
: [name]
dd-mm-yyyy
Religion
: [name]
(signed)
Marital Status
: [name]
Occupation
: [name]
Nationality
: [name]
Valid Until
: [name / dd-mm-yyyy)
BLOOD TYPE: -
(photograph)