Formulir Dial Up

  
  Type of Account :
1Entry 1Classic 1Executive 1Platinum
 
  Term :
1Monthly 16 Months 11 Year
 
  Full Name :
............................................... Date of Birth :..............................		  
  Address :
............................................... Postal Code :...............................		  
  Contact Phone No :
Home :.................................... Office :........................................		  
  ID # /KTP /SIM /Passport :
..................................................................................................		  
  Login Name : c c c c c c c c  
  Password : c c c c c c c c  
  Email Address :
.....................................@....... .globalxtreme.net
  
  Operating System :
cWin 3.x  cWin 95/98  cWin 2000/NT  cMac
cOther ..... 		 
Method of Payment
  1 Cash 1 DP : Rp. ................................................................................................
  1 Credit Card : 1Visa  1Master Card  1BCA Card
    Card No. : ....................................................... Expired Date ....... / .... / .........
    Name :
......................................................................................................
  1 Transfer To : PT INTERNET MADJU ABAD MILENINDO
    Account no : ......................................................................................................
    Bank : ......................................................................................................
         
  I agree to be bound by GlobalXtreme membership terms and conditions
 

Customer's Sign
Surabaya, ................................

 

( ............................................ )

 Dealer's Stamp

Official

 


( ............................................ )



MALANG
Jl.Retawu no 8
Malang-65112
telp.(0341)56 2000
info@mlg.globalxtreme.net
  BALI
Jl.Kerobokan no 388x
Kuta-Bali 80361
telp.(0361)736 833
fax.(0361)736 833
info@dps.globalxtreme.net