Contoh Pengisian Form 37 Kolom

FORM MIGRASI PESERTA  JENIS PESERTA PESERTA NAMA INSTANSI/BADAN/PERUSAHAAN KODE VIRTUAL VIRTUAL ACCOUNT ACCOUN T BANK TEMPAT PEMBAYARAN IURAN TANGGAl REGISTRASI NOMOR PKS KODE PKS MASA BERLAKU KODE TANGGUNGAN KODE KC KODE DATI2 PISA

No

.

No Kartu BPJS K)&ata#

Ko- Muta)' -'')' 3

2



T!l A$t'7  Brla$u Muta)'

Na"a L#!$a%



0

.>P 2>S >I 0>A 1>T

 J#') Statu) Kla"'# Ka;'#

T!l La&'r

T"%a "%att La&'r La&'r

--/" --/""/ "/++ ++++ ++

.>L 2>P

Statu)

.>BK? 2>K? >CH? la"at T"%at T'#!! 0>CM 1>TDK TAHU

R(

Ko- Po)

Ko- K
Na"a K
Ko- Ko- Fa)$) Na"a D)a/ Kl D)a T$,I

.

.0

.1

.

9

1175 750 0

11 119 91

CENG ENGKARENG ENG

3407 072 2

.3

.4

.5

26

2.

No"or Tl%o#

E"a'l

NPP / No"or P!a;a'/Kar+a;a#

Ja*ata# .>Tta%? 2>Ko#tra$? >Paru& ;a$tu

2

20

21

2

[email protected]

12345

R+MEN+ -

1

24

Kewarga Negaraan

Ga=' -a# Tu#=a#!a# Tta%

25

1=WNI, 2=WNA

1



3

4

5

3173014700640012 ANI

1

SEMA SEMAR RANG ANG

07 07/0 /08/ 8/19 1964 64

2

2

3173011701090053

3173012610610001 ANDI

2

26/10/1961

1

2

JL RAYA ASPAL NO 30

4

9

1175 750 0

11 119 91

CENG ENGKARENG ENG

3407 072 2

DURI KOSA OSAMBI MBI 01 0115 15U U01 015 5

Kl l! !" "M#$ M#$"% "%B!% !%S#& S#&%'(# '(#)%*JS *JS+,

3173011701090053

3173010106930010 BUDI

4

MEDAN

01/06/1993

1

1

JL RAYA ASPAL NO 30

4

9

1175 750 0

11 119 91

CENG ENGKARENG ENG

3407 072 2

DURI KOSA OSAMBI MBI 01 0115 15U U01 015 5

Kl l! !" "M#$ M#$"% "%B!% !%S#& S#&%'(# '(#)%*JS *JS+,

12345

1

01/01/2015

5000000

1

7

3173011701090053

3173011010950008 BADI

4

SEMA SEMAR RANG ANG

10 10/1 /10/ 0/19 1995 95

1

1

JL RAYA ASPAL NO 30

4

9

1175 750 0

11 119 91

CENG ENGKARENG ENG

3407 072 2

DURI KOSA OSAMBI MBI 01 0115 15U U01 015 5

Kl l! !" "M#$ M#$"% "%B!% !%S#& S#&%'(# '(#)%*JS *JS+,

12345

1

01/01/2015

5000000

1

12345

23

TMT Kr=a 9 ta#!!al $ar+a;a# a$t'7 "#=a-' %)rta BPJS:

7

Kl l! !" "M#$ M#$"% "%B!% !%S#& S#&%'(# '(#)%*JS *JS+,

22

.>Kla) I? 2>Kla) II

7

DURI KOSA OSAMBI MBI 01 0115 15U U01 015 5

081234567890

Kla) Ra;at

0001376847347

JL RAYA ASPAL NO 30

.2

Na"a Fa)$) Do$tr G'!'

0001376830192

MEDAN

4

Ko- Fa)$) Do$tr G'!'

0001376847551

3173011701090053

..

Na"a Fa)$) T$,I

4

7

.6

RT

2

0001376830372

2

No"or I#-u$ K%#-u-u$a# / Kartu I8'# T'#!!al S"#tara 9KITAS: / Kartu I8'# T'#!!al Tta% 9KITAP: 9')' . -'!'t No"or I#-u$ K%#-u-u$a#:

3

1

0

No Kartu Kluar!a

6

1

01/01/2015

5000000

1

1

01/01/2015

5000000

1

A)ura#)' La'##+a

No, Pol')

Na"a A)ura#)'

.

2

No, NP(P

No Pa))%ort



0

48.909.764.2509.000