| NO. | FORMULIR | NAMA LENGKAP | TANGGAL MASUK ISLAM | ALAMAT | TELEPON | SURAT KETERANGAN |
|---|---|---|---|---|---|---|
| 1 | - | AGRIPA SIR | 09 Apr 2003, Wednesday | TIBAN INDAH | - | 0 |
| 2 | - | DYAH PREMIYATI | 04 Jun 2003, Wednesday | - | - | 0 |
| 3 | - | BROERY | 01 Jun 2004, Tuesday | BADAR SRI MAS | 0812 7003 391 | 0 |
| 4 | - | NILA RISKA | 03 Jun 2004, Thursday | GREEN LAND | 0819 8170 15 | 0 |
| 5 | - | LAMBAS MARDONGAN SITOMPUL | 04 Jun 2004, Friday | RINDANG GARDEN | - | 0 |
| 6 | - | LENNY MARLINA SIAHAAN | 10 Jun 2004, Thursday | TAMAN SEJATI E/9 | - | 0 |
| 7 | - | LUCIANA BERTHA PIVAULINA | 18 Jun 2004, Friday | ANGGREK PERMAIUJ/23A | 0813 6463 5577 | 0 |
| 8 | - | EKA TAUFIK SYAHPUTRA | 23 Jun 2004, Wednesday | KURNIA DJAYA ALAM | 0812 7022 015 | 0 |
| 9 | - | CICIK SUCIATY | 25 Jun 2004, Friday | TIBAN 3 (RADIO KEI FM) | 0818 8594 35 | 0 |
| 10 | - | YUNIKE SARTI | 31 Jul 2004, Saturday | TIBAN 1 C/6 | 0813 6455 7870 | 0 |
| 11 | - | I WAYAN SUDIATMAJA | 12 Aug 2004, Thursday | BUMI LANCANG KUNING | 0852 6400 1976 | 0 |
| 12 | - | FIONITA ANDRIYANI | 21 Aug 2004, Saturday | KP HARAPAN SEI PANAS | 0813 6451 9721 | 0 |
| 13 | - | VICTORIANUS PURWOKO | 29 Aug 2004, Sunday | SUKAJADI LAMA | - | 0 |
| 14 | - | MIMI | 09 Sep 2004, Thursday | DUTAMASB7/2 | 0812 7011 235 | 0 |
| 15 | - | ENY | 14 Sep 2004, Tuesday | DUTA MAS A6/13 | 0856 6518 298 | 0 |