4. Tarikh didaftarkan pada H/M .......................................................................................................
5. Nama Suami .............................................................................................................................
(No. Kad Pengenalan ....................................................................) Tarikh Lahir .............................
Alamat .........................................................................................................................................
...................................................................................................................................................
6. Nama Isteri ...............................................................................................................................
(No. Kad Pengenalan ....................................................................) Tarikh Lahir .............................
Alamat .........................................................................................................................................
....................................................................................................................................................