PT.

MITRA TRANSAKSI INDONESIA (MTI)

RDTX Tower 23-25th Floor, Jl. Prof. Dr. Satrio Kav E IV No. 6
Mega Kuningan,Jakarta 12950, Indonesia
Telp No : , E-mail :

BERITA ACARA

Nama Merchant : ___________________________________________________________________

MID : ___________________________________________________________________
Alamat : ___________________________________________________________________
___________________________________________________________________
EDC : ________________ Unit
Kategori : Instalasi / Migrasi / Replacement / PM / CM Thermal / CM Problem / Pullout

No. SN EDC TID SN Sim Card SN Sam Card SN Adaptor Keterangan

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……………….., ……………….. 2024

Pihak Merchant Merchant Service

( ………………………… ) ( ………………………… )
*Nama Jelas & Stempel *Nama Jelas

Telp/HP : ……………………….