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Pria Bukan Perokok
Pria Perokok
Wanita Bukan Perokok
Wanita Perokok
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Bekerja
Belum Bekerja
Pelajar / Mahasiswa
Bukan Pelajar / Mahasiswa
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Dalam Ruangan / Kantoran
Luar Ruangan / Lapangan
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Kurang dari Rp. 2.500.000,-
Rp. 2.500.000,- s/d Rp. 5.000.000,-
Diatas Rp. 5.000.000,-
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Nama Lengkap Sesuai KTP *
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Bulan, Tanggal dan Tahun Lahir *
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Jenis Kelamin *
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Status Pekerjaan *
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Pekerjaan *
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Ruang Lingkup Pekerjaan *
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Pendapatan Per Bulan *
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Nomor Hand Phone Yang Bisa Dihubungi *
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Alamat Tempat Tinggal *
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Kode Pos *
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Alamat E-mail *
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