PT.

Cyberindo Aditama
Email: customercare@cbn.net.id

FORMULIR PERUBAHAN LOKASI INSTALASI Website: www.cbn.id

CHANGE OF INSTALLATION SITE FORM

DATA PELANGGAN - Customer Data

No. Pelanggan - Customer ID :

Nama pemilik rekening - Account holder : ____________________________________________________________________________________________

Tanggal lahir - Date of birth : __________________ Jenis Kelamin - Sex : Pria - Male Wanita - Female

No. Identitas - Identity No. (KTP/Passport/KMIS) : ____________________________________________________________________________________________

Nama perusahaan - Company name : ____________________________________________________________________________________________

Pihak yang dapat dihubungi - Contact person : ____________________________________________________________________________________________

Nomor untuk dihubungi - Contact number : Rumah - Residence : ________ - _______________ Handphone : ________ - ______________

Kantor - Office : ________ - _______________ Fax : ________ - ______________

E-mail : _________________________________________________________________________

PERUBAHAN LOKASI INSTALASI - Change of Installation Site

Perubahan Tempat Instalasi - Change of Installation Site

Lokasi/Alamat Instalasi - Installation Site/Address Alamat Instalasi dan Penagihan - Installation & Billing Address

Lokasi/Alamat Sebelumnya - Previous Site/Address

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Lokasi/Alamat Baru - New Site/Address

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Phone : ________ - _______________ Fax : ________ - _______________

Dengan ini saya menyetujui membayar Rp. 250.000,- (atau Rp. 500.000,- khusus area Bali) untuk biaya relokasi ke alamat/lokasi instalasi yang baru. Biaya yang dikenakan
akan dimasukkan kedalam tagihan bulan selanjutnya.
Catatan : Biaya yang tertera belum termasuk PPN 11%.

I hereby agree to pay Rp. 250,000,- (or Rp. 500,000,- for Bali area) relocation fee for new installation at the new address or site. The applicable fee will be billed
automatically on the following month’s invoice.
Note : The relocation fee has not include 11% VAT.

Perubahan lokasi/alamat instalasi akan diproses maksimal 10 hari kerja (tidak termasuk Sabtu, Minggu, dan hari libur).
The process of changing installation site will require a maximum of 10 working days (does not include Saturdays, Sundays, and holidays).

Harap paraf apabila Anda telah memahami dan menyetujui pernyataan di atas
Please sign if you have understood and agreed with the statement above

Tanggal - Date ___________________________________________________

_______________________________________________________________
Tanda tangan - Signature
CA-JKT-RRS-FRM-04102022-1.2