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Elektronik Form Penilaian Personal
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NAMA
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JENIS KELAMIN
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Laki-laki
Perempuan
UMUR
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STATUS PERKAWINAN
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Kawin
Tidak kawin
Cerai
ALAMAT KTP
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ALAMAT DOMISILI
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NOMOR KONTAK
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Apakah Anda merupakan Penyandang Disabilitas yang berhadapan dengan hukum?
Ya
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