001
REGISTRATION FORM
No. --.--/JBM/--- Tanggal/Date: -/0-/2018
DATA PELANGGAN | SUBSCRIBER DATA
Name Instansi / Badan Usaha :
Alamat | Address :
Phone :
Penanggung Jawab | Person in Charge :
Jabatan | Position :
Email :
Telpon Sellular | Handphone :
JENIS LAYANAN YANG DIINGINKAN | SERVICE PREFERENCE REQUEST
Beri tanda untuk layanan yang anda inginkan | For service preference request please thick
Web Housting
Wireless / 2GHz / 5GHz/ Microwave
Virtual Machine Fiber Optic Cable
Cloud Computing
Internet / Local Loop......................Mbps Media Layanan | Use for
Broadband Wireless / 2GHz / 5GHz/ Microwave
Fiber Optic Cable
Dedicated
INFORMASI TAGIHAN | BILLING PAYMENT METHOD
Biaya Pemasangan | Installation Fee :
Biaya Langganan Maentenance /bulan | Monthly Fee:
Penanggungjawab | PIC :
Telepon | Telephone :
Telepon Sellular | Handphone:
Pembayaran | Payment
Tunai | Cash Transfer
Debet | Debit
Kami menyetujui Syarat dan Sales & Marketing Finance & Acconting Instaler
ketentuan Berlangganan
| herewith We agree to Terms of
subscription
Rp. 6.000
Materai | Stamp Duty
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