Trial Form Biznet Dedicated Internet / Biznet DataComm

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

Installation Information
Company Name/Customer Name:

Contact Phone : Contact Mobile Phone :

Contact Email :

Node A Node B
Building Name : Building Name :

Complex : Complex :
Street : Street :

District Name* : District Name* :

City : City :
Island Name : Island Name :
Province : Province :
Country : Country :
Postal Code : Postal Code :
* District Name equals to Kecamatan

Additional installation information

(Please specify in detail)

Installation and Technical Contact Person

Name : Mobile :

Phone : Email :

Service Information
Service : [ ] Biznet Dedicated Internet
Service Capacity:
[ ] 10 Mbps [ ] 35 Mbps [ ] 70 Mbps [ ] 150 Mbps [ ] 400 Mbps
[ ] 15 Mbps [ ] 40 Mbps [ ] 80 Mbps [ ] 175 Mbps [ ] 500 Mbps
[ ] 20 Mbps [ ] 45 Mbps [ ] 90 Mbps [ ] 200 Mbps [ ] 750 Mbps
[ ] 25 Mbps [ ] 50 Mbps [ ] 100 Mbps [ ] 250 Mbps [ ] 1 Gbps
[ ] 30 Mbps [ ] 60 Mbps [ ] 125 Mbps [ ] 300 Mbps
[ ]Others (please specify)

Signature
PT Supra Primatama Nusantara - Biznet Dedicated Internet / DataComm Trial Form - Confidential Information 5/8/2019
 Service : [ ] Biznet DataComm
Service Capacity:
[ ] 1 Mbps [ ] 25 Mbps [ ] 250 Mbps [ ] 500 Mbps [ ] 10 Gbps
[ ] 2 Mbps [ ] 50 Mbps [ ] 90 Mbps [ ] 1 Gbps
[ ] 5 Mbps [ ] 75 Mbps [ ] 100 Mbps [ ] 2.5 Gbps
[ ] 10 Mbps [ ] 100 Mbps [ ] 250Gbps [ ] 5 Gbps
[ ]Others (please specify)

Service Type Biznet DataComm: [ ] P-to-P [ ] P-to-M [ ] M-to-M

We already applied Dual Stack system (IP v4 & v6) on IPv6 Addressing: Yes No
our network and we highly recommend you to add IPv6 to
your network.
Trial request date

Marketing Information
How do you know Biznet?
[ ] Newspaper: [ ] Biznet Website
[ ] Magazine: [ ] Search Engine
[ ] Radio: [ ] Referenced by friend/family/colleague
[ ] Billboard/Baliho [ ] Others:

Authorization
 We hereby confirm that the information above is true Signature & Company Stamp Print Name:
and agree to be bound by Biznet’s Terms and
Conditions which written on the proposal of
Dedicated Internet and we are the authorized to
signed the services order form.
Date:
 Biznet has the right to refuse this application without
any explanation

 Biznet’s Terms and Conditions may change at any

time without prior notice

 For credit card payment, we hereby authorize Biznet

to charge the credit card for service type we chose.

Please attach the following copies

[ ] Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer

Signature
PT Supra Primatama Nusantara - Biznet Dedicated Internet / DataComm Trial Form - Confidential Information 5/8/2019