Alamat : Jl. Girilaya No.

18 Surabaya - 60254
031-5610838, 081 553995572, 081 249 989 872, 087 854677739 Email : klaudiacars@gmail.com

PESANAN
ORDER
Nama Pemesan
: .............................................................................................................
Name of Passenger

Alamat / Telepon : .............................................................................................................

Address / Phone

Tujuan : .............................................................................................................
Destination

Tipe Mobil : ............................................................... No. Mobile.........................

Type of Vehicle Car Number

Berangkat : Tanggal Jam

Departure Date
................................................ ...................................
Time

Tiba Kembali : Tanggal Jam

Arrival Date
................................................ ...................................
Time

Biaya
Initial Charges
: Rp. ................................................................. (Hours)...........................

Tambahan/Overtime
Extra Charges
: Rp. ................................................................. / Hours...........................

Jumlah : .............................................................................................................
Total

Keterangan
Notes
: .............................................................................................................

Nama Pengemudi : .............................................................................................................

Driver’s Name
Karcis Tol / Tiket Ferry Penyeberangan Untuk Kendaraan dibayar Pemakai

PETUGAS TANDA TANGAN PEMESAN

Official Passenger’s Signature

( ................................... ) ( ..................................... )