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Rp. ................................................................................................ |
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1
Credit Card |
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Card No. |
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Expired Date ........ / ............. |
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Name |
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1
Transfer |
To |
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PT INTERNET MADJU ABAD MILENINDO |
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Account no |
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Bank |
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I agree to be bound by GlobalXtreme
membership terms and conditions |
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Customer's Sign
Surabaya, ................................
( ............................................ )
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Official
( ............................................ )
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