CUSTOMER'S FORM Name of Company/Business (Nama Pervahess) Business Address ( Alamat Pengiviman Fakrur ) Phone & Fax ( Telp & Fax ) Handphone Number Email Payment Tax Registered Number ( NPWP ) Business Line ( Bidang Usaha ) Diisi bila Pelanggan dengan Kredit atau Toko :PT PRI YAKA KARYA. ‘J1Pontianak No. 23 GKB Sukomulyo Manyar, Gresik - 031-3950242, +: 08133166696 priyakakarya@yahoo.co.id feash Credit with Term Limit Awal Oo Others Limit Tambahan 1 Limit Tambahan 2 Limit Tambahan 3 74,862. 983.9.612.000 Jaga Fonekmest Foto Perusahaan / Toko *vajib melampickan omer tclepon rumah kantor Tel We confirm that the information given above is true (Kami memastikan bahwa keterangan yang diberikan diatas adalah benar) Name ( Nama ) Title/Designation (Jabatan ) Date ( Tanggal ) Note: Please kindly attach (Tolong lampirkan): a NPWP 3 SIUP TDP > SPPKP Fax KTP Direkur/ KTP gung Jawab *lampirkan foto Bosue\ _ Priyono Proje Manager 38_SeBtemper 3031 ia Dy ‘Signature ( Tanda Tangan ) Approved By (Filled out by PT. Sinar Quality Inemusa ) PT. PRIVYAKA as ‘Company's Stamp (Cap Perusahaan) Di Ajukan Oteh Seles Di Buat Oleh Admin Sales ‘Accounting Director