PT.

ASNET DATA SOLUTION

Jl. Ronggo Warsito Perum Kranggan Permai No. A1 Pojok, Garum - Blitar
No. Telp. 0342-8176041 · No. HP. 0821-1394-8178
Email: info@as-net.id

FORMULIR PENGAJUAN BERHENTI LANGGANAN

Tanggal: 01 Oktober 2023 | No. Berhenti : S-OFF23100002
DATA PELANGGAN
No. Registrasi : 21252108052 Nama Perusahaan / :-
Nama Pelanggan : HARDA SULISTYA BAYU Instansi
NIK : 3505100407940000 NPWP :-
No. HP : 85651031550 No. Telp. Instansi :-
Email :- Alamat : Dsn Tlogo II Rt 001 Rw 004 Tlogo
Agen / Marketing : BASORI ADI / BASORI ADI Kanigoro Blitar
Desa / Kode Pos : TLOGO / 66171

DATA PEMASANGAN
Alamat Pemasangan : Dsn Tlogo II Rt 001 Rw 004 Tlogo Latitude : -8.1242081
Kanigoro Blitar Longitude : 112.198478
Desa / Kode Pos : TLOGO / 66171
Kecamatan / : KANIGORO / BLITAR
Kabupaten

Tagihan

No Nama Tagihan Jumlah Tagihan

1 Biaya Pembongkaran Perangkat Rp. 35.000

Subtotal Rp. 35.000

Kode Unik Rp. 1

Total Rp. 35.001

Alasan Berhenti:

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Minggu, 01 Oktober 2023

Supervisor Admin Pelanggan

( .................... ) ( .................... ) ( HARDA SULISTYA BAYU )