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<table border="0" cellspacing="0" cellpadding="0" width="660" class="MsoTableGrid" style="width: 495pt; margin-left: 0.9pt; border-collapse: collapse; border: medium none">
	<tbody>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span><span>1.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			</span></span></span><span>Foto
			Copy Kartu Tanda Penduduk</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>2 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>2.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			</span></span></span><span style="letter-spacing: -0.05pt">F</span><span style="letter-spacing: -0.05pt">oto Copy </span><span><span>&nbsp;</span><span style="letter-spacing: -0.05pt">Su</span><span>rat<span style="letter-spacing: 0.05pt"> </span>I<span style="letter-spacing: -0.05pt">z</span>in
			<span style="letter-spacing: 0.05pt">P</span>r<span style="letter-spacing: -0.1pt">a</span>kt<span style="letter-spacing: -0.15pt">i</span>k<span style="letter-spacing: 0.05pt"> </span>A<span style="letter-spacing: -0.05pt">p</span><span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.1pt">t</span>eker<span style="letter-spacing: -0.1pt"> </span>(<span style="letter-spacing: -0.05pt">S</span>I<span style="letter-spacing: 0.05pt">P</span><span style="letter-spacing: -0.15pt">A</span>);</span></span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>3.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			</span></span></span><span style="letter-spacing: -0.05pt">Foto Copy Denah
			Bangunan/Denah Lokasi</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>4.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><span style="letter-spacing: -0.05pt">Su</span><span>rat<span style="letter-spacing: 0.05pt"> y</span>a<span style="letter-spacing: -0.05pt">n</span>g<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: 0.05pt">m</span>e<span style="letter-spacing: -0.05pt">n</span><span style="letter-spacing: -0.1pt">y</span>atakan<span style="letter-spacing: -0.1pt">
			</span>st<span style="letter-spacing: -0.1pt">a</span>t<span style="letter-spacing: -0.05pt">u</span>s<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">b</span>a<span style="letter-spacing: -0.05pt">ngun</span>an
			<span style="letter-spacing: -0.05pt">d</span>alam<span style="letter-spacing: 0.1pt"> </span><span style="letter-spacing: -0.05pt">b</span>e<span style="letter-spacing: 0.05pt">n</span>t<span style="letter-spacing: -0.15pt">u</span>k<span style="letter-spacing: 0.05pt"> </span>A<span style="letter-spacing: 0.05pt">k</span><span style="letter-spacing: -0.1pt">t</span>e<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">H</span>ak<span style="letter-spacing: -0.05pt"> </span><span style="letter-spacing: 0.05pt">M</span>ili<span style="letter-spacing: -0.1pt">k</span><span style="letter-spacing: 0.05pt">/</span><span style="letter-spacing: -0.05pt">S</span><span style="letter-spacing: -0.1pt">e</span>wa<span style="letter-spacing: -0.05pt">/</span>K<span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.15pt">n</span>trak</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span><span>5.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><span style="letter-spacing: 0.05pt">D</span><span>aftar <span style="letter-spacing: -0.15pt">A</span>sisten A<span style="letter-spacing: -0.15pt">p</span><span style="letter-spacing: 0.1pt">o</span><span style="letter-spacing: -0.1pt">t</span>eker<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: -0.05pt">dg</span>n <span style="letter-spacing: 0.05pt">m</span>e<span style="letter-spacing: -0.05pt">n</span>ca<span style="letter-spacing: -0.15pt">n</span>t<span style="letter-spacing: -0.05pt">u</span><span style="letter-spacing: 0.05pt">m</span><span style="letter-spacing: -0.1pt">k</span>an <span style="letter-spacing: -0.05pt">n</span>a<span style="letter-spacing: 0.05pt">m</span><span style="letter-spacing: -0.1pt">a</span>,<span style="letter-spacing: 0.05pt"> a</span><span style="letter-spacing: -0.15pt">l</span>a<span style="letter-spacing: 0.05pt">ma</span>t,<span style="letter-spacing: -0.1pt"> </span>ta<span style="letter-spacing: -0.05pt">ngg</span>al l<span style="letter-spacing: -0.05pt">u</span>l<span style="letter-spacing: -0.05pt">u</span>s,<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.15pt">n</span><span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.05pt">m</span><span style="letter-spacing: 0.05pt">o</span>r<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: -0.05pt">S</span>I<span style="letter-spacing: 0.05pt">P</span>A</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>6.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			</span></span></span><span>Asli <span style="letter-spacing: -0.05pt">d</span>an
			</span><span style="letter-spacing: -0.05pt">Foto Copy</span><span> Ter<span style="letter-spacing: -0.15pt">p</span>er<span style="letter-spacing: -0.15pt">i</span><span style="letter-spacing: -0.05pt">n</span>ci alat<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">p</span>er<span style="letter-spacing: -0.15pt">l</span>e<span style="letter-spacing: -0.05pt">ng</span>ka<span style="letter-spacing: -0.05pt">p</span>an a<span style="letter-spacing: -0.05pt">po</span><span style="letter-spacing: -0.1pt">t</span>ek</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span><span>7.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><span style="letter-spacing: -0.05pt">Su</span><span>rat<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">p</span>er<span style="letter-spacing: -0.05pt">n</span><span style="letter-spacing: 0.05pt">y</span>at<span style="letter-spacing: -0.1pt">a</span>an
			<span style="letter-spacing: -0.05pt">d</span>ari A<span style="letter-spacing: -0.05pt">po</span><span style="letter-spacing: -0.1pt">t</span>eker<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: 0.05pt">P</span>e<span style="letter-spacing: -0.05pt">n</span><span style="letter-spacing: -0.15pt">g</span>el<span style="letter-spacing: 0.05pt">o</span>la A<span style="letter-spacing: -0.15pt">p</span><span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.1pt">t</span>ek<span style="letter-spacing: 0.05pt"> </span>(<span style="letter-spacing: -0.15pt">A</span><span style="letter-spacing: -0.05pt">P</span><span style="letter-spacing: 0.15pt">A</span>)<span style="letter-spacing: 0.05pt"> </span>ba<span style="letter-spacing: -0.05pt">h</span>wa
			ti<span style="letter-spacing: -0.05pt">d</span><span style="letter-spacing: -0.1pt">a</span>k<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">b</span>e<span style="letter-spacing: -0.1pt">k</span>erja
			<span style="letter-spacing: -0.1pt">t</span>e<span style="letter-spacing: -0.1pt">t</span>ap
			<span style="letter-spacing: -0.05pt">p</span>a<span style="letter-spacing: -0.05pt">d</span>a <span style="letter-spacing: -0.05pt">p</span>er<span style="letter-spacing: -0.05pt">u</span>sa<span style="letter-spacing: -0.05pt">h</span>aan
			far<span style="letter-spacing: -0.05pt">m</span>asi <span style="letter-spacing: -0.15pt">l</span>ain <span style="letter-spacing: -0.05pt">d</span>an ti<span style="letter-spacing: -0.05pt">d</span>ak<span style="letter-spacing: -0.05pt"> </span><span style="letter-spacing: 0.05pt">m</span>e<span style="letter-spacing: -0.05pt">n</span>ja<span style="letter-spacing: -0.05pt">d</span>i A<span style="letter-spacing: -0.15pt">p</span><span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.1pt">t</span>eker<span style="letter-spacing: -0.05pt"> </span><span style="letter-spacing: 0.05pt">P</span>e<span style="letter-spacing: -0.05pt">n</span><span style="letter-spacing: -0.15pt">g</span>el<span style="letter-spacing: 0.05pt">o</span>la A<span style="letter-spacing: -0.15pt">p</span><span style="letter-spacing: 0.05pt">o</span>tik (A<span style="letter-spacing: 0.05pt">P</span>A)<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">d</span>i
			A<span style="letter-spacing: -0.15pt">p</span><span style="letter-spacing: 0.05pt">o</span>t<span style="letter-spacing: -0.1pt">e</span>k<span style="letter-spacing: 0.05pt"> </span>lai<span style="letter-spacing: -0.05pt">n</span></span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>8.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			</span></span></span><span>Asli <span style="letter-spacing: -0.05pt">d</span>an
			</span><span style="letter-spacing: -0.05pt">Foto Copy</span><span> <span style="letter-spacing: -0.05pt">Su</span><span>rat<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.15pt">I</span><span style="letter-spacing: -0.05pt">z</span>in Atasan <span style="letter-spacing: -0.05pt">b</span>a<span style="letter-spacing: -0.05pt">g</span>i <span style="letter-spacing: -0.05pt">p</span><span style="letter-spacing: -0.1pt">e</span><span style="letter-spacing: 0.05pt">mo</span><span style="letter-spacing: -0.15pt">h</span><span style="letter-spacing: 0.05pt">o</span>n <span style="letter-spacing: -0.15pt">p</span>e<span style="letter-spacing: -0.05pt">g</span>a<span style="letter-spacing: 0.05pt">w</span>ai
			<span style="letter-spacing: -0.05pt">n</span>e<span style="letter-spacing: -0.15pt">g</span>eri,<span style="letter-spacing: 0.05pt"> </span>a<span style="letter-spacing: -0.05pt">nggo</span>ta A<span style="letter-spacing: -0.1pt">B</span>RI Dan <span style="letter-spacing: -0.05pt">p</span>e<span style="letter-spacing: -0.05pt">g</span>awai i<span style="letter-spacing: -0.05pt">n</span>sta<span style="letter-spacing: -0.05pt">n</span>si<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: -0.05pt">p</span><span style="letter-spacing: -0.1pt">e</span><span style="letter-spacing: 0.05pt">m</span><span style="letter-spacing: -0.1pt">e</span>ri<span style="letter-spacing: -0.05pt">n</span>tah<span style="letter-spacing: 0.05pt"> </span>lai<span style="letter-spacing: -0.05pt">nn</span><span style="letter-spacing: 0.05pt">y</span>a</span></span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span><span>9.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><span style="letter-spacing: -0.05pt">Su</span><span>rat<span style="letter-spacing: 0.05pt"> P</span>er<span style="letter-spacing: -0.15pt">n</span><span style="letter-spacing: 0.05pt">y</span>ataan
			<span style="letter-spacing: -0.15pt">p</span>e<span style="letter-spacing: 0.05pt">m</span>il<span style="letter-spacing: -0.15pt">i</span>k<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.1pt">s</span>ara<span style="letter-spacing: -0.05pt">n</span>a ti<span style="letter-spacing: -0.05pt">d</span>ak<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.1pt">t</span>erli<span style="letter-spacing: -0.05pt">b</span>at<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.15pt">p</span>ela<span style="letter-spacing: -0.05pt">ngg</span>aran<span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.05pt">p</span>e<span style="letter-spacing: 0.15pt">r</span>at<span style="letter-spacing: -0.05pt">u</span>ran
			<span style="letter-spacing: -0.05pt">p</span>er<span style="letter-spacing: -0.05pt">und</span>a<span style="letter-spacing: -0.05pt">ng</span>-<span style="letter-spacing: -0.05pt">und</span>an<span style="letter-spacing: -0.05pt">g</span>an
			<span style="letter-spacing: -0.05pt">d</span>i <span style="letter-spacing: -0.05pt">b</span><span style="letter-spacing: 0.1pt">i</span><span style="letter-spacing: -0.05pt">d</span>a<span style="letter-spacing: -0.05pt">n</span>g
			<span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.05pt">b</span>at</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>10.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp; </span></span></span><span><span>&nbsp;</span>Foto Copy </span><span><span>&nbsp;</span><span style="letter-spacing: -0.05pt">S</span><span>ITU</span></span><span>-HO</span><span style="letter-spacing: -0.05pt">/</span><span style="letter-spacing: 0.05pt">P</span><span>a<span style="letter-spacing: -0.05pt">p</span>an <span style="letter-spacing: -0.1pt">Re</span>kla<span style="letter-spacing: -0.05pt">m</span>e</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>11.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp; </span></span></span><span style="letter-spacing: -0.05pt">Foto Copy </span><span>Akt</span><span>a</span><span style="letter-spacing: 0.05pt"> </span><span style="letter-spacing: -0.15pt">N</span><span style="letter-spacing: 0.05pt">o</span><span>taris<span style="letter-spacing: -0.1pt"> </span>A<span style="letter-spacing: -0.05pt">n</span>ta<span style="letter-spacing: -0.1pt">r</span>a A<span style="letter-spacing: -0.05pt">p</span><span style="letter-spacing: 0.05pt">o</span>t<span style="letter-spacing: -0.1pt">e</span>ker<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: -0.05pt">d</span>an
			I<span style="letter-spacing: -0.05pt">n</span><span style="letter-spacing: 0.05pt">v</span>e<span style="letter-spacing: -0.1pt">s</span>t<span style="letter-spacing: 0.05pt">o</span>r Apoteker</span>
			</p>
			</td>
			<td width="96" valign="top" style="width: 1in; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt; line-height: normal" class="MsoListParagraphCxSpLast">
			<u><span>1 Lembar</span></u>
			</p>
			</td>
		</tr>
		<tr>
			<td width="564" valign="top" style="width: 423pt; padding: 0in 5.4pt">
			<p style="margin: 0in 0in 0.0001pt 17.1pt; text-indent: -0.25in; line-height: normal" class="MsoListParagraphCxSpFirst">
			<span style="letter-spacing: -0.05pt"><span>12.<span style="font: 7pt &quot;Times New Roman&quot;">&nbsp;&nbsp; </span></span></span><span style="letter-spacing: -0.05pt">F</span><span style="letter-spacing: 0.05pt">o</span><span style="letter-spacing: -0.1pt">t</span><span>o<span style="letter-spacing: 0.1pt"> </span><span style="letter-spacing: -0.1pt">C</span><span style="letter-spacing: 0.05pt">o</span>p<span style="letter-spacing: 0.05pt">y</span><span style="letter-spacing: -0.1pt"> </span>Re<span style="letter-spacing: -0.1pt">k</span><span style="letter-spacing: -0.05pt">om</span>e<span style="letter-spacing: -0.05pt">nd</span>asi
			<span style="letter-spacing: 0.05pt">D</span>ari<span style="letter-spacing: -0.1pt"> </span><span style="letter-spacing: -0.05pt">P</span>e<span style="letter-spacing: -0.05pt">ngu</span>r<span style="letter-spacing: -0.05pt">u</span>s<span style="letter-spacing: 0.05pt"> </span>Ca<span style="letter-spacing: -0.05pt">b</span>a<span style="letter-spacing: -0.05pt">n</span>g IAI Ka<span style="letter-spacing: -0.05pt">b</span>. <span style="letter-spacing: -0.05pt">S</span>i<span style="letter-spacing: -0.05pt">drap</span></span>
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			<u><span>1 Lembar</span></u>
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