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FORMULIR PENDAFTARAN BANTUAN USAHA MIKRO

1. Nama : ______________________________________________________

2. NIK : ______________________________________________________

3. No. NIB/IUMK : ______________________________________________________

4. Alamat Lengkap : ______________________________________________________

______________________________________________________

5. Alamat Usaha : ______________________________________________________

______________________________________________________

6. Bidang/Jenis Usaha : ______________________________________________________

7. No. HP/WA : ______________________________________________________

8. No. Rekening : ______________________________________________________

9. Asset (Rp.) : ______________________________________________________

10. Omset/Tahun (Rp.) : ______________________________________________________

11. Email : ______________________________________________________

12. NPWP (Jika memiliki) : ______________________________________________________

Cilegon, Maret 2020

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