Formulir Dial Up Bali

  
  Type of Account :
1Bach 1Choppin 1Vivaldi 1Beethoven 1Mozart
 
  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 :
.....................................@dps.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 : Acc. No. 1460-991-991
    Bank : BCA Kuta
         
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Customer's Sign
Surabaya, ................................

 

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

 Dealer's Stamp

Official

 


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MALANG
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Malang-65112
telp.(0341)56 2000
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  BALI
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Kuta-Bali 80361
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