Biznet Networks - Service Change Form

Note: Please provide detailed information so we can provision the service faster. Please scan & email the Order
Form, or fax to +62-21-5700580.

Customer Information
Customer ID:
Previous Company Name/Customer Name: New Company Name/Customer Name:

Previous NPWP: New NPWP:

Previous Address/Billing Address: New Address/Billing Address:

Contact Person: Contact Person:

Contact Title: Contact Title:
Phone: Phone:
Fax: Fax:
Mobile: Mobile:
Email: Email:
Notes: Notes:

Service Information
Previous Service Type: New Service Type:

Previous Monthly Fee: New Monthly Fee:

Effective Date: Notes:

Installation Information
Previous Installation Address - Node A: New Installation Address - Node A:

Previous Installation Address - Node B: New Installation Address Node B:

*for relocation

Payment Information
Previous Payment Type: New Payment Type:

For payment with credit card, please fill the information

Credit Card Type: Master Card/Visa Credit Card No:
Credit Card Name: Credit Card Exp Date:

Signature
PT Supra Primatama Nusantara - Service Change Form - Confidential Information 8/29/2017
Authorization
This service change form will only be valid if terms and Signature & Company Stamp Print Name:
conditions is attached.
Note:
1. Pelanggan setuju untuk tunduk dan terikat dengan
seluruh syarat dan ketentuan Layanan sesuai dengan
jenis layanan yang digunakan oleh Pelanggan;
2. Syarat dan Ketentuan dapat berubah sewaktu waktu
tanpa pemberitahuan terlebih dahulu kepada Date:
Pelanggan

Please attach the following copies

[ ] Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer
[ ] Credit Card (Front & Back) for payment with credit card only

Signature
PT Supra Primatama Nusantara - Service Change Form - Confidential Information 8/29/2017