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g bermerk gpp
PROPINSI JAWA TIMUR
KABUPATEN GRESIK
Nama : Reilly Permana Adi
Tempat/tgl. lahir : MADIUN 22 mei 1990
Jenis kelamin : Pria Golongan Darah : B
Alamat : Citarum 10
RT/RW : 001/004
Desa : Randuagung
Kec : Kebomas
Kab : Gresik 61121
Agama : Islam Status perkawinan : duda anak tiga
Pekerjaan : mahasiswa
berlaku hingga 22-2-2012
(persis ma yg dKTP)
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