Tanggal : .....................................................

Id Pelanggan : .....................................................
No Pemesanan : .....................................................
Formulir Berlangganan
Informasi Pelanggan Informasi Layanan
Nama Perusahaan Total Service
....................................................................................................... Site/Lokasi/Link Internet Dedicated
Alamat Perusahaan √ Internet Bisnis
....................................................................................................... Media Internet Corporate
....................................................................................................... Metro-E Internet Broadband
....................................................................................................... Fiber IP Public
Kota : ....................................................Kode Pos : ................... Wireless Other
Propinsi : ................................................................................. Other
Telepon : .................................................................................
Faksimile : ................................................................................. Bandwidth
Email : ................................................................................. Mbps/Gbps
NPWP Perusahaan
....................................................................................................... Tanggal Permohonan Layanan Aktif
Alamat Faktur Pajak ........................................................................................................
....................................................................................................... Termin Kontrak
....................................................................................................... ........................................................................................................
....................................................................................................... Status Layanan
Penanggung Jawab Baru Perpanjangaan
Nama Upgrade ...................................
.......................................................................................................
Jabatan Migrasi [ ] Ya [ ] Tidak
.......................................................................................................
No KTP Biaya
....................................................................................................... Biaya Pemasangan
Telepon : ................................................................................. ........................................................................................................
Faksimile : ................................................................................. Biaya Deposit
Email : ................................................................................. ........................................................................................................
Penanggung Jawa Teknis Biaya Bulanan
........................................................................................................
Nama
....................................................................................................... Lokasi Pemasangan
Jabatan Nama Pengguna Layanan
....................................................................................................... ........................................................................................................
No KTP Alamat Pengguna Layanan
....................................................................................................... ........................................................................................................
Telepon : ................................................................................. ........................................................................................................
Faksimile : ................................................................................. ........................................................................................................
Email : ................................................................................. Penanggung Jawab
Informasi Pembayaran ........................................................................................................
Penanggung Jawab Pembayaran Telepon : .........................................................................
.......................................................................................................
Alamat Penagihan
.......................................................................................................
.......................................................................................................
.......................................................................................................
Kota : ....................................................Kode Pos : ................... Tanggal : ......................................................................................
Propinsi : .................................................................................
Telepon : .................................................................................
Faksimile : .................................................................................
Email : .................................................................................
Diisi oleh Pihak Puskomedia
Tanggal : .................................................................................

Jenis Usaha
[ ] Jasa [ ] Pemerintahan
[ ] Industri [ ] Media Massa
[ ] Keuangan [ ] Lainya
[ ] Perdagangan

Kelengkapan Dokumen
[ ] Fotokopi KTP [ ] Fotokopi NPWP