Nomor SKCK : ………………………………………………
DAFTAR PERTANYAAN SURAT KETERANGAN CATATAN KEPOLISIAN
NAMA PEMOHON
: ...................................................................................
KEPERLUAN
: ...................................................................................
Yang bertanda tangan di bawah ini : The undersigned is : a. b. c. d. e. f. g. h. i. j. k. l.
Nama : ................................................................................................................. Name Tempat / Tanggal lahir : ...................................................................................... Place / Date of Birth Agama : ............................................................................................................... Relgion Kebangsaan : ....................................................................................................... Nationality Jenis Kelamin : .................................................................................................... Male / Female Kawin / Tidak Kawin : .......................................................................................... Married / Not married Pekerjaan : .......................................................................................................... Occupation Alamat Sekolah : ................................................................................................. Current address Nomor Kartu Penduduk : ..................................................................................... Citizen card number Nomor Pasport : ................................................................................................... Pasport Number No.KITAS / KITAP : ............................................................................................. Stay Permit No. Nomor Telp./Hp : ................................................................................................. Phone number
Menerangkan hal - hal sebagai jawaban / keterangan atas pertanyaan- pertanyaan diajukan sebagai berikut : Explain things as answer / explanation for the questions posed as follows : I. Hubungan Kekeluargaan ( Relationshop ) : 1. Istri / Suami (wife / Husband) : a. Nama : ........................................................................................................... Name b. Umur : ........................................................................................................... Age c. Agama : .......................................................................................................... Religion d. Kebangsaan : ................................................................................................ Nationality e. Pekerjaan : ..................................................................................................... Occupation f. Alamat : ......................................................................................................... Address 2. Bapak Sendiri ( Father ) : a. Nama : ........................................................................................................... Name b. umur : ............................................................................................................ Age c. Agama : .......................................................................................................... Religon
d. e. f.
Kebangsaan : ................................................................................................ Nationality Pekerjaan : ..................................................................................................... Occupation Alamat Sekarang : ......................................................................................... Current address
3. Ibu Sendiri (Mother) : 1. Nama : .................................................................................................. Name 2. Umur : ................................................................................................... Age 3. Agama : ................................................................................................ Religion 4. Kebangsaan : ........................................................................................ Nationality 5. Pekerjaan : ............................................................................................ Occupation 6. Alamat : ................................................................................................. Address 4.
Saudara sekandung / Tiri (Siblings) : Nama (Name) / Umur (Age) / Pekerjaan (Job) / Alamat (Address) a. ............................ ................ .................... ..................................... b. ............................ ................ .................... ..................................... c. ............................ ................ .................... ..................................... d. ............................ ................ .................... .....................................
5.
Riwayat Sekolah (Education History) : a. ............................ Tahun Lulus (Year of Graduation) b. ............................ Tahun Lulus (Year of Graduation) c. ............................ Tahun Lulus (Year of Graduation) d. ............................ Tahun Lulus (Year of Graduation)
: : : :
......................... ......................... ......................... .........................
II. Tersangkut Perkara Pidana dan Pelanggaran (Criminal case Lodged and Abuse) : 1.
Perkara Pidana (Criminal Case) : a.
Apakah Saudara pernah tersangkut perkara pidana ? / Have you ever caught in a criminal case ? ................................................................................................................................
b.
Dalam perkara apa? / In what kind of case ? ................................................................................................................................
c.
Bagaimana putusannya dan Vonis hakim? / What is the decision of the judge and verdict ? ................................................................................................................................
d.
Apakah Saudara sedang dalam proses perkara pidana? Kasus apa? / Are you currently in the process of a criminal case ? What kind of case ? ................................................................................................................................
e.
Sampai Sejauh mana proses hukumnya? / To what extent is the legal process?
......................................................................................................................
2. Pelanggaran (Violation) 1. Apakah saudara pernah melakukan pelanggaran hukum dan atau normanorma social / Have you ever violated the law and social norms or other? ....................................................................................................................... 2. Pelanggaran hukum atau norma-norma sosial apa?/ What kid of violations of the law? ....................................................................................................................... 3. Sampai sejauh mana prosesnya? / To what extent is the process? ....................................................................................................................... III. INFORMASI LAIN (OTHER INFORMATION) 1. Riwayat Pekerjaan/ negara-negara yang pernah dikunjungi/ work experience and countries you have ever visited before : (Sebutkan tahun berapa, dalam rangka apa dan negara mana yang dikunjungi) ...................................................................................................................... 2. Kesenangan/ Kegemaran / Hobi / Pleasure / Fondness / Hobbies: ...................................................................................................................... ...................................................................................................................... 3. Alamat yang mudah dihubungin (no. telepon) Contact no. in case of emergency (phone number): ...................................................................................................................... IV. Sponsor ( khusus orang asing / foreigners ) 1. Disponsori oleh (Sponsored by) : .................................................................. 2. Alamat Sponsor (Sponsor Address) : ............................................................ 3. Telp./Fax. (Tel./Fax.) : ................................................................................... 4. Jenis Usaha (Type of Bussiness) : ................................................................
Keterangan diatas saya buat dengan sebenarnya atas sumpah menurut kepercayaan saya, apabila dikemudian hari ternyata keterangan ini tidak benar maka saya sanggup dituntut berdasarkan hukum yang berlaku. / I have made the above statement the truth according to my own belief, if in the near future this information turn out to be false then I could be prosecuted under applicable laws.
.............................. ...........................................
(…………………………………………)
KARTU Tik 1. a. Nama : b. Alias : 2. Kebangsaan a. Tgl. No. KTP b. Tgl. / No. Pasport
: :
3. A g a m a
:
4. a. Tgl. Lahir/ Umur b. Tgl. Lahir/ Umur
: :
PHOTO
5. Alamat :
6. Perubahan Alamat :
7. Kedudukan dalam keluarga :
8. a. Anak Bapak : Anak Ibu : b. Alamat :
9. Pekerjaan : 10. a. Nama Suami / Istri :
Umur :
b. Nama Bapak Suami / Istri :
11. Sanak/Saudara yang :menjadi Tanggungan :
c. Nama Ibu Suami / Istri : d. Alamat :
Alamat :
12. Anak-anak : 1.
Umur :
Nama : 4.
2.
5.
3.
6.
13. Ciri-ciri Badan : : 1. Rambut 4. Tinggi :
Umur :
2. Muka : 5. Tanda Istimewa :
3. Kulit :
14. Rumus Sidik Jari : 15. Riwayat Sekolah : 1.
Tahun Lulus :
2. 3. 4. 16. Kesenangan/Kegemaran/Hobi : 17. Catatan Kriminal yang ada :
18. Data / Keterangan-2 lain :
Diisi menurut keadaan Tgl. : Kepala Kepolisian ......................................
