Nama : ______________________
No :
_______________________
TTL :__________________________________
Wafat : _________________________________
Jabatan
(disertai tahun) :
_________________________________
_________________________________
_________________________________
_________________________________
Tanggal
usulan dasar negara: ___________________________________
Usulan dasar
negara: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Nama :
_________________________________
TTL :__________________________________
Wafat : _________________________________
Jabatan
(disertai tahun) :
_________________________________
_________________________________
_________________________________
_________________________________
Tanggal
usulan dasar negara: ___________________________________
Usulan dasar
negara:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Nama : _________________________________
TTL :__________________________________
Wafat : _________________________________
Jabatan
(disertai tahun) :
_________________________________
_________________________________
_________________________________
_________________________________
Tanggal
usulan dasar negara: ___________________________________
Usulan dasar
negara: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Tempelkan foto
Panitia Sembilan beserta tanggal lahir dan tanggal wafat pada selembar kertas
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